What Is a Peer-to-Peer Review in the Prior Authorization Process?
When a written request isn’t enough to resolve a coverage disagreement, some insurers offer a more direct option: a conversation between the treating doctor and one of their own reviewing physicians.
The short answer
A peer-to-peer review is a phone conversation between the physician who requested a treatment and a physician working for the insurer, held to discuss the clinical reasoning behind a prior authorization request that has been denied or is at risk of denial. It gives the treating doctor a chance to explain the case directly, sometimes resolving the disagreement faster than a written appeal alone.
When this option becomes available
Peer-to-peer review typically comes into play after an initial denial, either as a step available before a formal written appeal or alongside one, depending on the insurer’s specific process. Not every plan offers it, and even where it exists, it’s usually optional rather than a mandatory stage everyone has to go through.
Who initiates the call
The request for a peer-to-peer review generally comes from the treating provider’s office, not from the patient directly, since the conversation is meant to be a clinical discussion between two physicians. A patient can typically ask the provider’s office whether requesting this option makes sense for their specific situation, but the call itself happens between the two doctors.
What tends to happen on the call
The treating physician generally walks through the clinical reasoning for the requested treatment — prior treatments tried, specific findings, and why the requested option fits the case — while the reviewing physician asks questions and compares that explanation against the plan’s coverage criteria, similar to the standard used in a broader medical necessity determination. The outcome is typically either an overturned denial, a reaffirmed denial, or a request for more documentation.
How it fits with a formal appeal
A peer-to-peer review doesn’t necessarily replace a formal appeal. If the call doesn’t resolve the disagreement, the standard denial and appeal process still applies, including the same deadlines for filing. For more on that formal path, see how to appeal a prior authorization denial. Because a peer-to-peer conversation can sometimes happen faster than a written appeal moves through the system, some providers use it as a first attempt before committing to the more formal route.
What it doesn’t guarantee
A peer-to-peer review is a conversation, not a promise of reversal. Both physicians bring their own read of the case, and the insurer’s reviewing doctor is still applying the plan’s specific criteria rather than substituting their own independent judgment. It’s best understood as an added opportunity for the clinical reasoning to be heard directly, rather than a shortcut that automatically changes the outcome.
A useful distinction
The peer-to-peer review exists specifically because some clinical nuance is hard to fully capture in paperwork. Knowing that this option exists, who typically has to request it, and how it relates to the broader appeal timeline helps set realistic expectations about what a single phone call can and can’t accomplish.