CurrentBaylor Scott & White Health PlanPolicy 244

Peer-to-Peer (P2P) Opportunity

Defines the payer's processes and timing requirements for offering providers a reasonable opportunity to discuss a treatment plan with a physician prior to issuance of an adverse determination; applies to Baylor Scott & White Health Plan lines of business and references Medicare and Texas Medicaid regulatory requirements where applicable.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyPeer-to-Peer (P2P) Opportunity

Policy CodePolicy 244

Change TypeNo material changes

Effective DateMar 1, 2026

Next Review DateFeb 26, 2027

Key ActionProviders must be afforded a reasonable opportunity to discuss services with a physician before an adverse determination; timelines differ by review type and must meet applicable prior authorization turnaround requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 business dayInpatient & outpatient expedited timeframe

3 business daysOutpatient standard timeframe

≥1 working dayProspective P2P notice

≥5 working daysRetrospective P2P notice

≥4 hours

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Concurrent P2P notice

Coverage Criteria and Scope

Timing and process criteria for Peer-to-Peer Opportunity

Peer-to-peer opportunity timing requirements (as defined by Texas Administrative Code and Texas Insurance Code):

Prospective reviews: At least one documented good faith attempt to contact the provider no less than one working day prior to issuing a prospective utilization review adverse determination.no less than 1 working day

See TAC definition of 'Reasonable opportunity' and plan timelines.

Retrospective reviews: At least one documented good faith attempt to contact the provider no less than five working days prior to issuing a retrospective utilization review adverse determination; statutory requirements also require written notice of a retrospective adverse determination to the provider and patient within 30 days of claim receipt (with one allowable extension of up to 15 days under specified conditions).no less than 5 working days; written notice within 30 days (may extend once up to 15 days)

See TAC definition and Texas Insurance Code Sec. 4201.305.

Concurrent and post-stabilization reviews: Provide a reasonable opportunity prior to issuing a concurrent or post-stabilization adverse determination; the plan defines a minimum of 4 hours for concurrent P2P and requires notice for denial of post-stabilization care not later than one hour after the request when applicable.concurrent: minimum 4 hours; post-stabilization: within 1 hour

See plan timelines and Texas Insurance Code Sec. 4201.304.

Timing when processing timeframe is due: If the allotted peer-to-peer time has not expired but the processing timeframe for making a determination is approaching, the plan must make its decision and notify based on the information available at that time; once an adverse determination letter is issued the formal P2P opportunity is closed and the provider must initiate an appeal to seek reconsideration.N/A

See plan guidance on processing timeframes and effect of issuance.

Documentation and disclosure during P2P: The utilization review agent must provide the clinical basis for its decision, describe documentation or evidence that could be submitted on appeal, supply a telephone number for provider contact, and maintain records of the P2P offer and outcome (date/time offered, date/time discussion occurred if any, and discussion outcome).N/A

See TAC requirements and plan recordkeeping obligations.

A determination that a service is or is not medically necessary under this policy does not guarantee that the service is a covered benefit under a member’s plan. Benefit coverage is governed by the applicable benefit plan documents (Evidence of Coverage / Summary Plan Description) and any controlling federal or state rules or regulations. In the absence of a controlling mandate, plan documents determine coverage and, in the event of a discrepancy, the plan document supersedes this policy.

Provider Responsibilities and Procedures

Prior Authorization

Offer a reasonable P2P before adverse determination and meet review-specific timelines

Providers must be afforded a reasonable opportunity to discuss services with a physician before an adverse determination. Timelines differ by review type and must meet the Medicaid/HHS/plan turnaround requirements: prospective — no less than 1 working day prior to a prospective adverse determination; retrospective — no less than 5 working days prior to a retrospective adverse determination; concurrent — minimum of 4 hours prior to a concurrent adverse determination; post-emergency stabilization — within 1 hour prior to a post-stabilization adverse determination. Medicaid-specific determination timeframes (e.g., inpatient and outpatient expedited: 1 business day; outpatient standard: 3 business days) also apply and peer-to-peer arrangements must be made within those timeframes.

Prospective: no less than 1 working day prior to issuance of adverse determination
Retrospective: no less than 5 working days prior to issuance of adverse determination
Concurrent: minimum of 4 hours prior to issuance of adverse determination
Post-emergency stabilization: within 1 hour prior to issuance of adverse determination
Medicaid turnaround times (inpatient/outpatient expedited: 1 business day; outpatient standard: 3 business days) must be met

Key Definitions

Reasonable opportunity — definition

DefinitionAt least one documented good faith attempt to contact the provider of record that provides an opportunity for the provider of record to discuss the services under review with the URA during normal business hours prior to issuing a prospective, concurrent, or retrospective utilization review adverse determination.

Prospective review timingNo less than one working day prior to issuing a prospective utilization review adverse determination.

Retrospective review timingNo less than five working days prior to issuing a retrospective utilization review adverse determination.

Concurrent/post-stabilization timingPrior to issuing a concurrent or post-stabilization review adverse determination (plan defines minimums for concurrent and post-stabilization in timeline guidance).

Background and Regulatory Context

This policy implements regulatory requirements that when a utilization review agent (URA) questions the medical necessity, appropriateness, or investigational status of services, the provider must be given a reasonable opportunity to discuss the case with a physician prior to issuance of an adverse determination. The policy adopts applicable provisions from the Texas Administrative Code and Texas Insurance Code and incorporates the TAC requirement that the URA provide the clinical basis for the decision and explain what documentation could be submitted on appeal.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyPeer-to-Peer (P2P) Opportunity

Policy CodePolicy 244

Change TypeNo material changes

Effective DateMar 1, 2026

Next Review DateFeb 26, 2027

SourceLink

On This Page

Note

Disclose clinical basis and required evidence during P2P

During the P2P discussion the utilization review agent (URA) must explain the clinical basis for its decision and describe any documentation or evidence that, if submitted on appeal, might lead to a different utilization review decision. The URA must also provide a telephone number so the provider may contact the URA to discuss the pending adverse determination.

Provide the clinical basis for the URA's decision
Describe documentation/evidence that could be submitted on appeal to change the decision
Supply the URA's telephone number for provider contact

Documentation Required

Document and retain P2P offer and outcome; provide on request

The utilization review agent must maintain records of the P2P offer and outcome and must submit that documentation to TDI on request. Required elements include the date/time the URA offered the opportunity, the date/time the discussion took place (if any), and the discussion outcome.

Date and time URA offered the opportunity to discuss the adverse determination
Date and time the discussion took place (if any)
Discussion outcome
Retain records and submit to TDI upon request

Denial Risk

If processing deadline arrives before P2P expires, decide on available information; denial closes P2P

If the allotted P2P time has not expired but the statutory or plan processing timeframe for a determination is due, the plan must make its decision/notification based on the information available at that time; once an adverse determination letter is issued the formal P2P opportunity is closed and the provider must initiate an appeal to seek reconsideration.

Plan must decide/notify within processing timeframes using available information if P2P window overlaps processing deadline
After issuance of the adverse determination letter, the formal P2P is closed and only an appeal can change the decision