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Peer to Peer Contact – The Essentials

What is a Peer to Peer call/contact?

A Peer to Peer call to a requesting physician is sometimes warranted to obtain supporting information for a requested treatment. In some cases the contact attempt is required, but in other cases it is simply requested by the provider, who wishes to discuss clinical findings.

If I am initiating Peer to Peer call, what do I say?

  • First, identify yourself as the reviewing Utilization Review physician for one for the provider’s patients. You may speak to the requesting physician, an associate physician, a nurse or other medical assistant who is familiar with the case.
  • In the event no one is available to speak at the time of the call, always leave a callback number. You may choose to leave your office or cell number, or you may leave Claims Eval’s phone number (916.797.9997), and we will notify you if the provider calls back.
  • Do always document every call attempt, and every message left, specifying whether you left it with staff (also document staff name), or in a voicemail. (See below for additional information regarding documentation.)
  • Prior to making your call, we recommend a review of submitted medical records and reports. This will give you an idea of talking points and information required to support the requested treatment.
  • With the exception of Texas modification/partial certifications, we ask that determinations not be discussed over the phone. If asked whether a treatment will be certified, an appropriate response might be that ‘a final review of guideline recommendations will be necessary before a decision can be rendered’.

When do I call?

You will find a Peer to Peer Availability section on your Claims Eval Doctor Dashboard, or the information will be specified via an email accompanying the file.  In either case, we provide information about when the call should occur, any hours of availability provided by the client, special instructions or alternate/additional phone numbers for the requesting physician. If no specific hours of availably are provided, please always ensure the calls are within normal business hours (9am-5pm) of the time zone in which the provider is located.

(Note:  In the event of multiple reviews for the same claimant, with the same treating physician, please use the same call information for each file, hopefully limiting the number of calls you will have to place.)

How do I document my call?

  • Document basic contact information: “On (date) at (time) a call was placed to the office of (provider name), (contact number called)”.
  • Specify if a message was left due to provider or assistant unavailability. Note whether the message was left with a specific individual, or via voicemail.
  • Specify if you discussed the case with the provider, an associate physician, a Nurse Practitioner or other assistant, such as a Medical Assistant.
  • If the discussion yields information not initially submitted with the medical records, please detail in your notes. This information could have significant bearing on the determination and could in fact change it with proper documentation.

As always, please feel free to contact us with questions or concerns regarding Peer to Peer contacts, or any other aspect of your work with us.