Providers

Prior Authorization Guidelines

Prior Authorization Lists

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A current list of Medical Services (Procedures, Products and Treatment) requiring Prior Authorization can be viewed on the Medical Services requiring Prior Authorization search

Upcoming Changes to Codes Requiring Prior Authorization

Upcoming code changes can be viewed on the Upcoming Code changes list

Prior Authorization Forms

Prior Authorization Request	Description	Submission Type
Authorization Request for Preservice	Utilization Management Prior Authorization Requests Please submit your request online (preferred) or by fax. For fax submissions, please include the PDF form and Fax to 801-213-1358	Submit Online Print PDF Form
Inpatient, ICF, SNF, Acute Rehab and LTAC	Prior Authorization Requests for Inpatient, ICF, SNF, Acute Rehab and LTAC Please submit your request online (preferred) or by fax. For fax submissions, please include the PDF form and Fax to 801-213-2132	Submit Online Print PDF Form
Behavioral Health/Substance Treatment	Prior Authorization Requests for Behavioral Health/Substance Treatment Please submit your request online (preferred) or by fax. For fax submissions, please include the PDF form and Fax to 801-213-2132	Submit Online Print PDF Form
Pharmacy Prior Authorization or Exception Requests	Retail Medication Prior Authorization Form Note: Pharmacy prior authorization ONLY. Medical prior authorization requests (including J-code) may be submitted via the Provider Portal. For authorization, please answer each question and fax this form PLUS chart notes back to the Health Choice Utah Prior Authorization Department at 385-425-4052.	Print PDF Form(s)
Request to Reopen an Organizational Determination for Medical Review	If you received a medical necessity denial and there is additional clinical information that may change the outcome of our decision, please submit this form and associated clinical to the fax numbers listed. Inpatient Stays: 801-213-2132 Outpatient Pre-service Requests: 801-213-1358	Print PDF Form

Peer to Peer Information and Form

Peer to Peer Review Request Form (PDF)

Peer to Peer Review

A peer-to-peer (P2P) review is a conversation over the phone between a licensed University of Utah Health Plan physician reviewer and the physician or treating practitioner who requested the authorization. A P2P conversation is not an additional level of review and is not an appeal. It is not intended to be a mechanism to overturn the denial.

The main purpose of a P2P is to better understand the rationale for the denial based on our medical polices and criteria used.

P2P conversations must occur prior to any appeal submission and are intended for services denied for medical necessity or investigational reasons. A P2P is not to be used to discuss situations where services were denied for any other reason.

To ensure that the requesting provider has received the rationale for the denial and has been informed of the criteria or medical policy used, a P2P must be requested:

After the provider has received the determination letter
Within 7 calendar days from the date of the determination letter

If you have questions regarding our P2P process, please contact our Customer Service department at:

Medicaid Plans: 833-981-0212 (toll free)
Individual and Business Plans: 833-981-0213 (toll free)

If the provider disagrees with our decision or has additional information to submit, the provider may submit an appeal following the P2P process.

Once a P2P form has been received, the requesting practitioner can expect a call to schedule the P2P within 2 business days

Peer-to-Peer (P2P) Process Frequently Asked Questions (FAQs)

What is a Peer-to-Peer (P2P)?	The peer-to-peer (P2P) process provides an opportunity for a member’s doctor to discuss the rationale and criteria used to make a specific authorization determination. It is not another level of review and not meant to take the place of an appeal.
What is the difference between a P2P and an appeal?	A P2P is a conversation between the requesting doctor or treating practitioner and a Health Plan Physician reviewer about a denial decision made for an authorization request. The purpose is to clarify why something was denied, but not intended to change the decision. An appeal is a formal request for a second review of the authorization. The appeal is to request a different determination.
How can I schedule a P2P?	The requesting provider may fill out a P2P form here. You may also reach out to our customer service department with questions.
When can I request a P2P?	A P2P is designed to be after the original coverage determination was made, but prior to an appeal. You have 7 calendar days from the date of the original determination to request the P2P.
How many P2P conversations can I request?	A P2P is offered one time per request determination. After the P2P is complete, if you do not agree with the original determination an appeal would be the appropriate step.
Who is able to request a P2P conversation?	The original requesting provider or a designated person from the provider’s staff can request a P2P.
Who takes part in the P2P discussion?	Only the original requesting provider or treating practitioner takes part in the conversation. We do not allow other office or non-medical staff to participate in the conversation with our physician reviewer.
How long does it take to schedule a P2P?	Once the P2P form has been submitted, we typically respond back with scheduling options within 2 business days. The appointment time will vary depending on physician availability, but we make every effort to schedule them as quickly as possible.
I have been told my case is not eligible for a P2P, why is this?	P2P are allowed for pre service denials, concurrent reviews, and post service denials when the notification letter indicates it as an option. P2P are intended for services denied for not being medically necessary or investigational. It must be requested before an appeal. It also must be requested within 7 calendar days of the original notification date. Most often cases are not eligible for P2P because they fall outside the approved timeframe window, an appeal has already been submitted, or the original request was denied for reasons other than medical necessity. These decisions must be appealed.
How to I request an Appeal?	You will need to fill out an appeal form. The instructions were included in the original determination letter. You may find the appeal form on our website here: Appeal Form You may also call customer service during business hours, and they can help you submit the appeal.
Can I request a P2P on an urgent case?	A peer to peer is not an additional level of review, so there is no Urgent Peer to Peer. If you would like a second review done on a case that is urgent, you may request an expedited appeal. Note: Expedited requests should be reserved for situations where application of the time frame for making routine care determinations could seriously jeopardize the life, health or safety of the member. It includes situations where lack of the requested treatment would subject the member to severe adverse health consequences.
If I withdraw my appeal, can I do a P2P?	Yes, an appeal is a formal request for a second review of the authorization. If you withdraw your appeal, you are eligible for the Peer to Peer. You may re-submit your appeal after the peer to peer.
If the member is still in the hospital, can I request a P2P while they are admitted? What about discharges over the weekend or on a holiday?	Yes, will respond within 2 business days of the request to set up a time for discussion.
Can the original authorization decision be changed or approved as a result of the P2P process?	The purpose of the P2P is to provide an explanation of the denial. A P2P conversation does not typically result in overturning the original decision.