How to prepare for a prior authorization peer-to-peer review

A peer-to-peer review is a phone call between the ordering physician and a reviewer at the health plan, usually after a denial or when one is pending. Done well, it's often the fastest way to overturn a decision. It's also short, so preparation decides the outcome.

It helps to know who's on the other end. In the 2025 AMA Prior Authorization Physician Survey, just 16% of physicians who take part in peer-to-peer reviews said the plan's representative often or always has the appropriate qualifications.

Before the call

• Have the denial letter open and know the exact reason given.
• Get the policy the plan relied on, and highlight the criteria in question.
• Map each criterion to your documentation, with dates: therapy completed, medications tried, exam findings, prior imaging.
• Know the deadline. Plans set windows for requesting a peer-to-peer, often short ones. They're on the denial notice or the plan's provider portal.

On the call

1. Ask the reviewer's name and specialty. Note both.
2. Lead with a one-minute summary: the patient, the requested service, and why now.
3. Walk the criteria in the policy's own order, stating where each one is documented.
4. Name the clinical risk of delay in concrete terms.
5. Ask directly: "Based on this, can you approve the request?"

After the call

Write down the date, time, reviewer, and outcome. If the denial is upheld, ask for the specific rationale in writing and the next appeal step and deadline. Then send a written appeal that answers the stated reason point by point.

Most peer-to-peer calls are lost on documentation, not argument. If the note already meets the criteria, the call is a formality, or never happens.

Source: 2025 AMA Prior Authorization Physician Survey. General information, not legal advice.