Peer-to-peer review after a behavioral-health denial: how to prepare

What is a peer-to-peer review?

It is an informal clinical conversation, offered by many payers, in which the treating clinician discusses a denial or a pending adverse decision with the payer's reviewer. It can change the decision on the spot. It is not a formal appeal, and it usually does not replace or pause the written appeal deadline.

In behavioral health, peer-to-peers come up most around concurrent review for residential, inpatient psychiatric, PHP and IOP care, and around ABA authorizations. Some payers offer the conversation before a decision is final, as a chance to add information; others offer it only after a denial. Read the notice or the payer's provider manual for which applies, and see the payer guides for the major behavioral-health payers.

When do you have to request it?

As soon as the denial or the reviewer's call arrives. Each payer sets its own window: one Florida Medicaid plan requires requests within 48 hours of the denial letter for behavior analysis services, and some plans offer the call only before a decision, others only after. If the window has closed, file a written appeal instead.

Record the time the denial was received, the deadline the payer gives for scheduling, and every attempt to schedule. If the payer cannot offer a slot inside its own window, ask for that in writing and file the expedited appeal in parallel so the clock is protected.

Who should be on the call, and who should the reviewer be?

The treating clinician should take the call, with UR staff preparing and listening. Ask for a reviewer with matching expertise, such as a psychiatrist for psychiatric care, an addiction specialist for SUD care or a child psychiatrist for adolescents. Federal rules for Medicare Advantage and Medicaid require reviewers with appropriate expertise.

Medicare Advantage organizations must have a physician or other appropriate health care professional with relevant expertise review a request before issuing an adverse medical-necessity decision. Medicaid managed care plans must have any denial or reduction made by someone with appropriate expertise in the enrollee's behavioral-health needs. In employer-plan appeals, the plan must consult a health care professional with appropriate training and experience who was not involved in the first decision.

This matters in practice. In the American Medical Association's 2025 survey, only 16% of physicians who had done peer-to-peers said the payer's reviewer often or always had appropriate qualifications (AMA survey, May 2026). Ask the reviewer's name, credentials and specialty at the start of the call and write them down.

What should the one-page brief contain?

Only what the clinician needs to answer the reviewer's stated reasons in a few minutes: the decision and dates, the criteria cited, the record facts that meet each criterion, what would happen at a lower level of care, and a specific, time-limited request. One page forces the case into the reviewer's frame.

The peer-to-peer prep sheet generator builds the same structure as a printable page.

What should the clinician say and ask on the call?

Lead with the patient's current risk and the specific facts that meet the cited criteria, then ask what would change the decision. Keep it clinical and concrete. Questions that pin down the reviewer's reasoning are as valuable as arguments, because the answers shape the written appeal if the call does not succeed.

1. 01Confirm the reviewer's name, credentials, specialty and the case reference number.
2. 02Ask the reviewer to state the specific criterion they believe is not met.
3. 03Answer that criterion with the dated facts from the brief.
4. 04Explain what is likely to happen at the lower level, based on this patient's history.
5. 05Make the specific request: how many days or units, and the step-down conditions.
6. 06If the reviewer will not approve, ask what documentation would change the decision and how to send it.

How should the call be documented?

Write a call note the same day: date and time, who was on the call, the reviewer's credentials, the reasons the reviewer gave, what was approved or denied, any documents the reviewer asked for and the reference number. Record what was actually said. That note becomes evidence if the case goes to a written appeal or external review.

If the decision is upheld, file the written appeal within the plan's deadline, expedited if the patient is still in care; the continued-stay guide covers the fast paths. If the reviewer named criteria you have not seen, request them in writing with the criteria request letter.