A peer-to-peer (P2P) discussion is a telephone conversation between a licensed Regence physician and the physician or clinical reviewer and the physician or other health care professional requesting authorization for coverage or to discuss a denial of a provider-administered medication pre-authorization request. A P2P is not an appeal, not specialty matched and not intended to overturn the denial. The purpose is to further understand the reason for the denial based on our medical or medication policies.
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
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
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.
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.