THE PEER TO PEER PROCESS
Date: 09/21/22
Providers may discuss medical, behavioral health, or pharmacy denial decisions with a physician or appropriate reviewer, who is the point of contact for a peer-to-peer discussion. The peer-to-peer process information is communicated verbally, as applicable, and is also included in the mailed denial letter.
Our Peer-to-Peer (P2P) availability policy Il.6.66 states:
- The requesting provider can discuss the case with the physician reviewer who made the initial denial decision
- If the physician reviewer who made the initial denial is unavailable, the requesting provider will have the option to discuss the case with another physician reviewer
- The physician reviewer will make a good faith effort to reach the requesting provider seeking the peer-to-peer discussion in the following manner:
Medical physician reviewers will outreach to the requesting provider at the scheduled peer-to-peer call time. If unable to complete the peer-to-peer discussion during initial contact, the medical physician reviewer will leave their availability and contact information for a return call from the requesting provider, then document their attempt in the case notes. The requesting provider has two business days after the initial attempt to contact the physician reviewer.
HEALTH PLAN or PRODUCT | P2P Phone Number |
|---|---|
Meridian Medicaid Plan (HealthChoice Illinois), Affordable Care Act: Physical Health | |
Meridian Medicaid Plan (HealthChoice Illinois), Affordable Care Act: Behavioral Health | |
YouthCare | |
National Imaging Association (NIA) | |
Turning Point | |
Medicare | 855-580-1689 x 8048049 |
Marketplace/Ambetter | |
New Century Health | |
Envolve Dental |