What a peer-to-peer call actually is
A peer-to-peer (P2P) is a structured phone or video conversation between the requesting physician — or a delegated physician advisor with documented authorization and case knowledge — and the payer's or UM vendor's medical director. The two clinicians discuss medical necessity before the determination becomes final, typically after an initial adverse determination or intent-to-deny. The medical director then approves the request, sustains the denial, asks for more documentation, or defers.
The “peer” framing is structural rather than strict. NCQA's utilization management standards require that a clinical peer reviewer be a licensed physician, in the same or similar specialty as typically manages the condition where required. URAC's Health Utilization Management standards use similar language. In practice, the medical director on the other end of the line is often not in the requesting specialty. Several state laws — California, Maryland, and Ohio among them — now require board-certified, same-specialty reviewers for certain denials, but the federal floor is weaker.
When payers request one
The most common trigger is an initial adverse determination — a denial or intent-to-deny, with a stated window for requesting a peer-to-peer before the determination becomes final. UM vendors increasingly route borderline cases to a peer-to-peer rather than denying outright, and providers can also request one during a first-level appeal. The peer-to-peer is always with whoever made the determination, which for ASC-relevant cases is often a UM vendor — eviCore, Carelon, Cohere, TurningPoint — rather than the payer of record.
- UnitedHealthcare states the window in the denial letter; it typically falls within the appeal window and, for expedited cases, can be as short as 24 to 72 hours from request.
- Cigna and its UM vendor eviCore state the window in the denial letter or vendor portal; non-urgent windows commonly sit within the appeal window, and urgent windows are tighter.
- Humana, often working through Cohere, specifies the window in the denial letter; Cohere's portal handles scheduling directly.
- BCBS plans, often working through Carelon, run peer-to-peer scheduling via the same provider portal used for the original request.
- Medicare Advantage plans operate under CMS-0057-F, which sets 72-hour expedited and 7-day standard timeframes for the underlying determination; peer-to-peer windows sit on top of those.
Why most peer-to-peers fail
The AMA's 2023 prior-auth survey reports that physicians spend roughly 12 hours per week on prior authorization activities. The same survey reports that 35% of practices employ staff who work exclusively on PA. Peer-to-peers are a disproportionate share of physician time, because the calls land with very short notice, often as a callback the medical director places when a slot opens. Surgeons report the same two complaints across payers: lack of advance notice, and inability to access the chart at the moment the call connects.
The pattern is familiar. The surgeon gets a five-minute warning between cases. The chart is not open, the PT notes are in a different system, and the conservative-care dates are from memory. The medical director on the line is a hospitalist or family-medicine physician, not an orthopedist. The conversation is six minutes long. The surgeon cannot cite the exact injection date or the failed PT duration. The director sustains the denial. The OR slot is in four days, the case is now in appeal, and the patient gets the call.
How Approva changes that
Today, Approva surfaces a case packet and a criteria checklist as the headline of the peer-to-peer brief. Instead of a wall of codes, the physician sees “5 of 6 Aetna criteria met, 1 needs documentation.” The brief includes the surgeon's name, the patient identifiers, the procedure in plain English, the conservative-care chain with dates, and the specific criterion the payer or UM vendor flagged. Each criterion cites the source page in the chart, so the physician on the call reads the exact PT note, MRI report, or injection date without hunting.
The rules library maps the case against the UM vendor's own clinical guidelines — eviCore MSK, Carelon clinical appropriateness, Cohere evidence-based, TurningPoint — rather than only the payer's published medical policy, because the UM vendor's criteria are the operational standard the medical director actually applies.
On the roadmap: a calendar handshake between the surgeon's office, the UM vendor's peer-to-peer line, and the ASC's OR schedule, so the call lands in a real slot rather than between cases; an option for the surgeon to delegate the call to a contracted physician advisor; and recording with transcript capture, subject to payer-contract terms and state two-party-consent laws.
The fractional physician advisor
A surgeon's time is the scarcest resource in the ASC. The call itself typically runs 10 to 20 minutes, but it sits inside a 30 to 60 minute prep, call, and callback window with very short advance notice, and that envelope blocks a clinical slot. Approva is being built to offer a fractional physician advisor option in specialties where the network has been contracted — a board-certified physician, typically same-specialty, who reads the brief in advance and takes the call from a desk with the chart open. The surgeon would remain the requesting physician of record; the advisor would act under documented authorization.
The advisor network is being built, not staffed at scale. NCQA and URAC standards govern the reviewer on the payer side, not the requester side, and the AMA's peer-to-peer best practices acknowledge that a requesting physician may designate a colleague with knowledge of the case to handle the call. UHC, Aetna, and Cigna generally accept a delegated physician with knowledge of the case, though some service categories and final-level appeals require the requesting surgeon personally.
What gets recorded back to the case
Whatever happens on the call lands on the case. Three fields matter most for appeals, for training the rules library, and for the ASC admin's view of payer behavior over time.
- The medical director's name and specialty. A specialty mismatch is itself an appeal argument under several payer policies and state laws.
- The decision rationale, captured as free text plus structured reason codes. The director's stated reasoning is the most valuable training signal for the payer rules library.
- Any new criteria the director invoked. If a criterion appears that was not in the original packet's mapping, the library learns it for next time.
Pitfalls to watch for
- Specialty mismatch. An orthopedic case reviewed by a family-medicine physician. Document the mismatch on the call and use it in appeal.
- No chart access at call time. Surgeon takes the call walking between ORs with no chart open. A pre-loaded brief is the mitigation.
- Missing conservative-care documentation. PT duration and dates, injection records, medication trials. The most common substantive reason for sustained denials on MSK and pain cases.
- Scheduling mismatch.Payer offers a 30-minute window during the surgeon's OR block. Without coordination, the surgeon misses the call and the denial stands.
- Recorded vs. not. Some payers and UM vendors record the call as policy; some do not. Provider-side recording is governed by state law (one-party vs. two-party consent). Capture the policy per call.
Site-of-service peer-to-peers
A second common pattern for ASCs is the site-of-service P2P. The clinical request is not in dispute — the payer wants the case done somewhere else. Sometimes that is a push toward office or hospital outpatient department over the ASC; sometimes it is the reverse, with the payer refusing the ASC for a case it wants done in a hospital outpatient setting. Either way the argument turns on chart facts, not on the procedure itself.
- ASA class and comorbidities that bear on monitoring and rescue capability.
- Anesthesia plan, airway risk, and equipment requirements for the specific procedure.
- Post-procedure monitoring and recovery needs, including expected length of stay.
- Prior conservative therapy and prior procedures in alternative settings.
- Geographic access for the patient and the realistic alternative site within the network.
The surgeon rarely carries these facts in their head mid-call. Approva is built to put the site-of-service argument — ASA class, anesthesia plan, monitoring needs, network-access notes — on a single brief, so whoever takes the call reads from the same page the chart supports.
Anesthesia peer-to-peers
Closely related but distinct is the anesthesia P2P. These are common in GI endoscopy, chronic pain — epidural injections, radiofrequency ablations, spinal cord stimulator trials — and in pediatric and special-needs cases. The dispute is rarely whether the procedure is necessary. It is MAC versus general, or anesthesia at all versus sedation administered by the proceduralist.
- ASA class and prior anesthesia history, including adverse reactions and failed sedations.
- Anxiety, cooperation, developmental, or behavioral factors that affect feasibility of conscious sedation.
- Anatomic difficulty — airway, positioning, prior surgery — and procedure-specific factors that drive the anesthesia plan.
- Comorbidities that change the risk profile of sedation by the proceduralist.
The anesthesia P2P is often led by the anesthesiologist, not the surgeon. Approva is built to brief whichever clinician takes the call, with the same criteria-checklist headline and the same chart citations underneath.
If your orthopedic, spine, or pain management ASC wants its peer-to-peer workflow built around the case packet, the criteria checklist, and a real handoff to a same-specialty physician advisor where one is available, request a demo and we will walk through your current process and where Approva fits.