Peer to Peer
Upon receipt of an adverse determination, providers may request a peer-to-peer discussion within five (5) business days from the notification. A “peer” is considered the Member’s or Provider’s clinical representative (licensed medical professional). Contracted external parties, administrators, or facility UM staff can only request that a peer-to-peer telephone communication be arranged and performed. but the discussion should be performed by a peer. When requesting a peer-to-peer discussion, please be prepared with the following information:
• Member name and Medicaid ID number
• Authorization number
• Requesting provider name, contact number, and best times to call
• Updated clinicals if available
• Authorization number
• Requesting provider name, contact number, and best times to call
• Updated clinicals if available
If a Medical Director is not immediately available, the call will be returned within two (2) business days. Every effort will be made to return calls as quickly as possible.