The primary role and purpose of a Peer-to-Peer (P2P) review is to provide additional information for discussion regarding a denied decision. A P2P offers an opportunity for conversation and to provide clinical context that may not have been included with the initial prior authorization request. Granting a P2P does not indicate that a decision will be overturned or reversed.

Visit our Prior Authorization web page and scroll down to "Peer-to-Peer Information and Forms" for an overview of the P2P process and answers to Frequently Asked Questions.

Please keep the following guidelines in mind:

SUBMISSION OF A REQUEST DOES NOT GUARANTEE A PEER-TO-PEER

A completed Peer-to-Peer Request Form (Medical or Pharmacy) is required; however, approval of a P2P is not guaranteed. If the case does not meet the outlined criteria, it may be directed to the appeals process.

TIMELINESS OF REQUEST

Requests must be submitted within 3 calendar days of the date of the denial letter. Requests submitted outside this timeframe will be referred to the appeals process.

SCHEDULING PERIOD

Health Choice Utah designates specific days and time blocks for P2P reviews. Available scheduling days are Monday, Tuesday, and Thursday, with both AM and PM time slots offered. Exceptions will not be made for P2Ps outside of these designated days and time blocks. 

Providers will not have an opportunity to reschedule a missed P2P appointment.

CALL AVAILABILITY

During the scheduled 30-minute window, Health Choice Utah will attempt to contact the provider twice. If unsuccessful, no further opportunity to reschedule will be provided before the matter is referred to the appeals process.

Please note that the P2P process is not specialty-matched and does not replace the appeals process.

Providers are encouraged to ensure complete and accurate submissions to facilitate effective scheduling and productive discussions.

Again, a Peer-to-Peer review provides an opportunity to discuss additional information and/or clinical context that may not have been available during the initial prior authorization review. A P2P does not replace the initial prior authorization review, nor does it guarantee that a decision will be overturned or reversed.

If you believe a Peer-to-Peer review is warranted, visit our Prior Authorization web page, scroll down to "Peer-to-Peer Information and Forms," then select, complete, and fax the appropriate (Medical or Pharmacy) Peer-to-Peer Review Request Form. Contact information is provided on each form if you have questions.

We appreciate the care and services you provide to our members.