How Do You Prepare for a Peer-to-Peer Review?
Get the denial reason and the payer's clinical criteria, match each criterion to a dated note in the chart, and put the physician who saw the patient on the call. The call is short and some windows are shorter, so the packet is built before anyone dials.
Written by Salman Saeed, CEO and Co-Founder · Reviewed by a Certified Medical Coder · 
In short: a peer-to-peer is a physician-to-medical-director call about a coverage decision. Confirm the window the day the denial arrives, ask for the criteria, and bring one dated chart note per criterion. If the call changes nothing, its reasons become the headings of the appeal.
How Do You Prepare for a Peer-to-Peer Review?
Get the denial reason and the clinical criteria the payer used, match each criterion to a line in the chart, and put the physician who saw the patient on the call. A peer-to-peer review is a conversation between your treating physician and the payer's medical director about a coverage decision, usually a denial of a prior authorization or an inpatient stay.
The call is short and the clock is shorter, so the work happens before it. Billing staff build the packet, the physician rehearses the case in one minute, and one person owns the reference number afterward. The prior authorization service page shows where this step sits in the wider workflow.
When Can You Ask for a Peer-to-Peer, and How Long Do You Have?
It depends on the payer, and the window can close before the denial letter reaches billing. The table quotes each payer's manual, and your contract can differ.
| Payer or program | What the rule or manual says | Where |
|---|---|---|
| UnitedHealthcare, standard clinical preservice denials | UnitedHealthcare offers a predecision window of 24 hours before finalizing a potential adverse determination. If the discussion happens in the window, new information can change the decision. If not, the decision is final and a later discussion is informational only. Expedited and administrative denials are excluded. | 2026 Care Provider Administrative Guide, ch. 7, p. 102 |
| UnitedHealthcare, Medicare Advantage after a final denial | Medicare does not allow the decision to be changed as a result of the peer-to-peer. Submit the additional information with a Medicare appeal or request a reopening. | Same page |
| UnitedHealthcare, preservice appeal | A peer-to-peer review is highly recommended before filing a preservice appeal. The expectation is that the physician or a designee has recently assessed the member. | Ch. 7, p. 100 |
| Aetna | Aetna offers providers the chance to present additional information and discuss the case with a peer-to-peer reviewer as part of the utilization review determination, with timing set by state, federal, CMS and NCQA requirements. | Aetna Office Manual, p. 31 |
| Medicare Advantage plans, initial review | A denial based on medical necessity must be reviewed by a physician or other appropriate health care professional with expertise suited to the services, who need not share the treating physician's specialty or subspecialty. | 42 CFR 422.566(d) |
| Original Medicare outpatient prior authorization list | No peer step. After a non-affirmation the provider may resubmit with the documentation required. | 42 CFR 419.82(e)(1) |
The practical rule is to ask on the day the denial arrives. If the payer's notice names a deadline or a phone number, the first call is to confirm the window in writing, before any clinical work starts.
What Should Be on the Desk Before the Call?
- The denial notice and its stated reason, with the reference number and the date it was issued.
- The criteria the payer applied. Aetna's manual says participating physicians may ask for a hard copy of the criteria used by calling the Provider Contact Center at 1-888-632-3862. For Medicare Advantage, ask which NCD or LCD the plan relied on, since 42 CFR 422.101(c)(1) bars denying basic benefits on coverage criteria that rule does not allow.
- A one-page case summary: diagnosis, what was tried and when, the result, the order and the proposed service.
- A criterion-by-criterion list with the page and date of the supporting note, laid out in the order the payer's criteria appear.
- The date, test result or imaging report that the reviewer is most likely to say is missing.
- The patient's current status, because an urgent change in condition may turn the case into an expedited request.
- A name and direct line for the physician, plus a backup who also assessed the patient.
If the denial shows CARC 50, the payer is saying the service was not medical necessity under its policy, and the CO-50 page covers the remark codes. If it shows CARC 197, the issue is a missing authorization, which is a different fix, so start from the CO-197 page.
How Should the Physician Run the Call?
- Confirm who is speaking, the reviewer's specialty, the patient identifier and the reference number, and note the time the call began.
- Give a short opening: the diagnosis, the proposed service and the one reason it cannot wait or be replaced.
- Go through the payer's criteria one at a time and state where each is met in the record. Say what was already tried and why it failed or was unsafe.
- Name the gap if there is one, and say what would close it, such as a test result you can fax or upload today.
- Ask for the outcome on the call. If the reviewer will not reverse, ask what specific evidence would change the decision and where to send it.
- Close by repeating the outcome, the next deadline and the name of the reviewer, and have a second person write it into the account.
UnitedHealthcare's guide adds that the physician or designee should be able to speak to salient elements of the care plan, so the person on the call should be someone who has recently seen the patient and not a scheduler reading a script.
What Does the Criterion List Look Like?
An outpatient cardiac catheterization is denied. The payer's criteria, as the reviewer reads them, appear in the left column. The right column is what billing pulls before the call. The criteria here are invented to show the layout and are not any payer's policy.
The point is the right-hand column. A reviewer who hears a dated note for each criterion has little reason to leave the case open, and the gap row shows the team knew what to fix.
What If the Call Changes Nothing or Comes Too Late?
Move to the written appeal and use what the call taught you. The reviewer's reasons become the headings of the appeal, and any evidence you offered on the call goes in the packet with the date it was offered. The CO-50 appeal post covers the appeal letter, and the denial management playbook sets the order across denial types.
For a service that has not happened, check whether the denial can be expedited. UnitedHealthcare lists three tests for urgent appeals, including a standard review time that risks the member's life or health and severe pain that cannot be managed without the care. If the service has already been given, its guide says an expedited appeal is not available and a claim goes in for the service provided. The retro authorization post covers late requests.
Keep a log by payer. Record the call date, the reviewer, whether the decision changed and why. After a quarter, the log shows which payers reverse on a call and which only reverse on appeal, so you can stop spending physician time where it does not help.
How We Handle Peer-to-Peer Requests
For cardiology and other specialty groups, we read the stated denial reason, request a peer-to-peer where the payer offers one, build the criterion-by-criterion packet for the physician and file the formal appeal if the call does not change the decision. Denials are worked within 48 hours. See the cardiology billing page or book a call.
- 2026 UnitedHealthcare Care Provider Administrative Guide, chapter 7 · UnitedHealthcare
- Aetna Office Manual for health care professionals · Aetna
- 42 CFR 422.566 Organization determinations · eCFR
- 42 CFR 422.101 Requirements relating to basic benefits · eCFR
- 42 CFR 419.82 Prior authorization for certain hospital outpatient department services · eCFR
- Claim adjustment reason codes · X12
We check every rule, code and deadline against the official source. See our editorial policy.
Common Questions
Straight answers from the team that does the work.
Ask a billing lead directly. A 20-minute call, Monday to Friday, 9am to 5pm Eastern.
01How do you prepare for a peer-to-peer review?
Get the denial reason and the payer's criteria, match each criterion to a dated note in the chart, and put the physician who saw the patient on the call. Prepare a one-page case summary and know the deadline, because some windows are short. UnitedHealthcare's predecision window is 24 hours for standard clinical preservice denials.
02Who takes part in a peer-to-peer review?
The treating or ordering physician, or a designee who recently assessed the patient, speaks with the payer's medical director or reviewer. UnitedHealthcare's guide describes a review between its medical director and the treating physician or prescribing practitioner. Billing staff prepare the packet and record the outcome but usually do not hold the clinical discussion.
03Can a peer-to-peer reverse a denial after it is final?
It depends on the payer and plan. UnitedHealthcare says that for Medicare Advantage, once a preservice adverse determination is made, Medicare does not allow the decision to change from the peer-to-peer, and a Medicare appeal or reopening is needed. Check the plan's manual before relying on a late call.
04Is a peer-to-peer review the same as an appeal?
No. Aetna's manual places the peer-to-peer inside the utilization review determination, and separately says the member or representative may appeal a denial through the complaint and appeal process. UnitedHealthcare recommends a peer-to-peer before a preservice appeal. Treat the call as a chance to change the decision first.
Talk to a Billing Lead.
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