Peer to Peer Conversations with a Network Health Physician
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Defines availability, purpose, and procedural rules for peer-to-peer conversations between treating providers (or designees) and a Network Health physician for denial cases involving medical necessity, including experimental/investigational determinations. Affects treating providers, their clinical designees, and Network Health utilization management staff.
No material clinical or coverage changes in this revision.
Peer-to-Peer Availability and Limits
P2P availability and limits
Peer-to-peer is available under these conditions and restricted under these circumstances.
How Providers Request and Use Peer-to-Peer (P2P)
Request a P2P to present new or clarifying clinical information
Provider may request a peer-to-peer (P2P) to provide new information or clarify the clinical presentation that was not available at the time of review, or to provide clarity about what is already in the clinical record. P2P is available for denials based on medical necessity and experimental/investigational determinations; it is not available for denials that are “not a covered benefit” or due to benefit exhaustion.
- Requesting provider: treating physician or a practicing clinical designee (physician assistant, nurse practitioner, resident, fellow, or clinical colleague) with firsthand knowledge and on staff at the facility.
- Outside vendors are not accepted as P2P participants except for specified exceptions (see Timeframe and exceptions).
Timeframe to request P2P and known exceptions
A provider must request a P2P within seven (7) days from the date of the determination. Ascension is a current exception and may request a P2P within seven (7) business days and may use an outside vendor designee (R1). Network Health reserves the right to make temporary exceptions.
- Standard timeframe: 7 days from determination date.
- Ascension exception: 7 business days and allowance for an outside vendor designee.
P2P unavailable after an appeal/grievance is filed
Network Health will not conduct a P2P if an appeal or grievance has already been filed for the same determination. If an appeal or provider dispute has been initiated, follow the appeal/grievance process rather than requesting a P2P.
- P2P unavailable once an appeal/grievance is filed; proceed via appeal/dispute processes.
Use P2P only to provide new/clarifying clinical information — not to debate decisions
P2P is intended to add new information or clarify the record and is not a forum to reiterate information already submitted or to debate the reviewer’s decision. If the provider disagrees after review of all pertinent clinical information, the appropriate next step is to file an appeal or provider dispute.
- Do not use P2P to repeat existing record details or to argue the decision.
- If disagreement persists after P2P review, initiate an appeal or provider dispute.
Key Terms
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.