When to ask for one
Before you file. The window is set by your plan rather than by regulation for most plans, and many stop offering a peer-to-peer once an appeal is filed, so ask on the day the denial arrives rather than after you have drafted anything.
What to do
Ask for it the day the denial arrives, before you draft anything
Call the number on the denial letter and ask whether a peer-to-peer is available on this decision, who requests it, and by when. Ask that question first, because the answer decides your order of operations. Filing the appeal first can close the door, and nothing about drafting an appeal gets easier for having waited.
Understand that your clinician makes the call, not you
A peer-to-peer is clinician to clinician, so you cannot be on it and cannot make the request stick by yourself. What you can do is start it: tell the prescribing or operating clinician's office that the denial is clinical, that a peer-to-peer is available, and give them the number and reference from the letter. Offices do not always initiate this unprompted.
Send your clinician the plan's own criteria before the call
The call is short and it turns on the plan's written criteria, not on general clinical merit. Find the specific criterion the denial named, and send it with the parts of the record that speak to it. A clinician arguing that the patient meets the plan's criteria wins more of these than one arguing the criteria are wrong.
Get the date, the name, and the outcome in writing
Whatever happens, record when the call was requested, when it happened, who the plan's reviewer was, their specialty, and what they said. If the call reverses the denial, get the reversal in writing rather than relying on the call. If it does not, that record goes into the appeal.
If the plan refuses or does not schedule it, log that too
A refused or unscheduled peer-to-peer is not a dead end, it is a fact about the plan's process, and it belongs in the appeal alongside the substance. Note the date, who you asked, and what they said. Then file the appeal on time — a peer-to-peer that never happens must not be allowed to eat your deadline.
Why the order matters more than the call does
Most plans treat a peer-to-peer as part of utilization review, which is the stage the decision is in before you appeal it. Once you file, the case moves into the appeal process and many plans will tell you the peer-to-peer is no longer available because the matter is now under formal review.
That is why this page sits before the appeal pages rather than among them. The call itself is often brief and sometimes changes nothing. The cost of getting the order wrong is losing the option entirely, and it is a free option: a reversal at this stage leaves every level of appeal still available to you if it does not work.
The one thing that must not happen is a peer-to-peer eating your appeal deadline. Ask for the call, and keep counting the days on the letter while you wait.
Where a consultation is actually required, and where it is not
For a Medicaid managed care plan there is a federal hook. Under 42 CFR 438.210(b)(2)(ii), the state's contract with the plan must require it to consult with the requesting provider for medical services when appropriate. That is worth naming in a Medicaid appeal. It is also hedged: the duty runs through the state's contract rather than to you, and nobody has defined when consultation is appropriate.
For an ERISA or commercial plan, there is no federal right to a peer-to-peer before the decision. What federal law gives you comes later, at the appeal: under 29 CFR 2560.503-1(h)(3)(iii), an appeal turning on medical judgment must be decided in consultation with a health care professional with appropriate training and experience in the field of medicine involved. That is a requirement about who the plan consults, not a conversation you can demand.
So for most plans, ask what the process is rather than asserting a right. The request costs nothing, plans usually offer it, and the refusal — if it comes — is itself worth having in the record.
Common questions
- Can I be on the peer-to-peer call?
- No. It is a conversation between two clinicians, and that is the point of it. You can make sure it happens, make sure your clinician has the plan's criteria beforehand, and get the outcome recorded afterwards.
- What if I already filed my appeal?
- Ask anyway, and do not withdraw the appeal. Some plans still take the call, some do not, and practice varies by plan and by reviewer. What you should not do is withdraw a filed appeal to make a peer-to-peer possible, because your deadline is running and the call carries no guarantee.
- The plan agreed on the call. Do I still need anything in writing?
- Yes. A verbal reversal is not an authorization. Ask for the approval or the corrected determination in writing, and keep counting your appeal days until it arrives.
- Does this apply to a written exclusion?
- Usually not. If the plan document excludes the service outright, there is no clinical question for two clinicians to discuss, and the argument is about the exclusion's scope and legality instead. The denial-shape pages cover that.
Where to go next
Sources for the legal points on this page
- Medicaid managed care: the plan must consult the requesting provider when appropriate
Federal — Medicaid managed care (MCO, PIHP, PAHP) · effective in force
42 CFR 438.210(b)(2)(ii) — under (b) Authorization of services, each contract must require that the plan 'consult with the requesting provider for medical services when appropriate'
Status: settled · source-checked 2026-08-09 · primary source verified: 2026-08-09
- The ACA appeal framework: internal appeal, then binding external review
Federal — non-grandfathered group health plans and issuers · effective in force
29 CFR 2590.715-2719 — (b)(2)(ii)(B) urgent-care 72 hours, (b)(2)(ii)(F)(1) deemed exhaustion, (c)(2)(xi) state external review binding, (d)(2)(i) four-month federal external review window, (d)(2)(iv) immediate coverage on reversal; 29 CFR 2560.503-1 — (c)(2) no more than two appeals before civil action, (h)(3)(i) 180 days from receipt, (h)(3)(ii) independent reviewer, (h)(3)(iii) health professional on medical judgment
Status: settled · source-checked 2026-08-06 · primary source verified: 2026-08-06
Also on this page, without a citation yet
- That most commercial and employer plans offer a peer-to-peer as a matter of their own utilization-review practice rather than because any law requires it. This is why the page tells you to ask what YOUR plan's process is instead of asserting a right — but no statute or case is cited for the general proposition here.
These are specific and checkable and we have not yet checked them against a primary source. Treat them as a starting point rather than as settled, and do not put them in an appeal without confirming them.