Manage Peer-to-Peer Reviews

Peer-to-Peer review is the process where the medical director connects with the requesting provider to discuss the actual or potential reason for denial of an authorization request. These discussions provide transparency, help the medical director justify reasoning, and direct the provider towards appropriate care delivery, while avoiding lengthy dispute and appeal processes.

Even though a medical director makes a decision after a comprehensive review of the request, there can still be conflicting opinions between the medical director and provider. The peer-to-peer review helps both parties to discuss the medical appropriateness, requested-setting, level and quality of care, and finally come to a conclusion.

The utilization management nurse checks the availability of the medical director and requesting provider and schedules this peer-to-peer review meeting, either before or after a medical director denies a request.

• Schedule Peer-to-Peer Review Meetings
  As a nurse, help resolve conflicting opinions, allow open communication, and ensure a complete review process by scheduling peer-to-peer discussions between the medical director and the requesting provider.
• Conduct a Peer-to-Peer Review
  As a medical director, clarify clinical information and explain review outcome decisions to the requesting provider by conducting timely peer-to-peer discussions.