Peer-to-peer review

A peer-to-peer (P2P) discussion is a telephone conversation between a licensed Regence physician and the health care provider to discuss a denial (e.g., related to a behavioral, non-behavioral or provider-administered medication) resulting from a medical necessity review determination. During the P2P, our physician and the provider will discuss the member’s circumstances relative to appropriate clinical criteria and our policies.

Medical P2P discussions

P2P discussions may only happen before an appeal has been submitted and only for services that are denied for medical necessity or investigational reasons. A P2P discussion can only be requested for:

  • Pre-service denials
  • Concurrent denials
  • BCBS Federal Employee Program (FEP): Post-service denials in which the member has liability and we have issued a denial letter indicating a P2P is available

Learn more about our appeals process.

Note: For Medicare Advantage members, a P2P can be submitted before or after an appeal.

To ensure that the provider has received the denial rationale and has been informed of the criteria used for the review, a P2P discussion must be requested:

  • After the provider has received the determination letter and
  • Within 15 calendar days from the date of the determination letter

To request a P2P discussion, submit a Medical Peer-to-Peer Review Request form. For discussions involving FEP members, submit the FEP Peer-to-Peer Review Request form.

No additional information will be accepted as part of the discussion. If the provider disagrees with our decision or has additional information to submit, the provider may submit an appeal following the process outlined in the denial letter and/or Notice of denial of medical coverage form included with the determination letter.

Pharmacy P2P discussions

If you would like to speak with a clinical reviewer about the denial of a provider-administered medication pre-authorization request, please complete the Pharmacy Peer-to-Peer Review Request form (provider-administered medications) to arrange for a P2P discussion. For retail (self-administered) medications, please call Pharmacy Customer Service at 1 (844) 765-6827.

Note: All medication-related calls will be routed to a Regence clinical pharmacist. If there are questions that the clinical pharmacist is unable to answer, the clinical pharmacist will schedule a call with a Regence medical director.