Denied Before You Got the Care: The Phone Call That Can Reverse It

The letter arrives before the care does. Your plan will not approve the MRI, the surgery, or the medication your doctor ordered. This is a prior authorization denial — prior authorization is approval your plan requires before it will pay for certain care.

The letter makes the no sound final. It is not. There is a phone call that reverses many of these denials, often within days, and the letter rarely explains it. It is called a peer-to-peer review.

What a peer-to-peer review is

A peer-to-peer review is a phone call between your doctor and a doctor who works for the insurance plan. Your doctor explains why the care is needed for you, specifically. The plan's doctor can change the decision on the call.

Why does a phone call work? Because the first denial usually comes from a checklist. Plans compare the request against written clinical criteria — the plan's list of conditions under which it pays for that care. If the paperwork does not match the list, the request is denied, sometimes without anyone reading your chart closely. The peer-to-peer puts the person who knows your case on the phone with a person who can change the answer.

One honest caution: the peer-to-peer is the plan's own process. Most plans offer one, but it is not a right written into most laws, and the rules — who can request it, and by when — vary by plan. The denial letter, or the plan's provider services line, says how it works for yours. Some plans only allow it within a short window after the denial, so move early.

You can't make the call, but you can make it happen

The call happens between doctors. You will not be on it. What you do is set it in motion:

Call your doctor's office, say you received a prior authorization denial, and ask them to request a peer-to-peer review with the plan. Give them the denial letter — it has the reference number and the reason the plan used. Offices handle these regularly; your call is what moves yours up the pile.

The letter owes you more than a no

The denial letter must state the specific reason. And you can ask for the checklist itself. If your plan is employer-sponsored, the federal claims rule (29 C.F.R. § 2560.503-1) says that when a denial relied on an internal rule or guideline, a copy

will be provided free of charge to the claimant upon request

Most other private plans, including marketplace plans, must follow the same internal claims rules under 45 C.F.R. § 147.136. Ask for the criteria in writing. Your doctor can then speak to the exact line your case supposedly failed — which is what wins a peer-to-peer.

The clock is already running

A prior authorization request is what the rules call a pre-service claim — a claim decided before you get the care. On employer plans, the plan must decide it

within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after receipt of the claim by the plan

and if your situation is urgent,

as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the claim by the plan

(29 C.F.R. § 2560.503-1(f)(2); the plan can extend the 15 days once, with notice). Deadlines differ on some other plan types and in some states, so check your plan documents.

The part people miss: a peer-to-peer usually does not pause your deadline to file a formal appeal — most plans give you 180 days from the denial. Treat the call as the fast lane and the written appeal as the road. If the call fails, appeal: on an appeal involving medical judgment, an employer plan must consult, in the rule's words, a

health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment

That is a stronger look than the checklist got. How to write the appeal, step by step.

Do this

1. Read the denial letter. Write down the reference number, the stated reason, and any deadline it names.
2. Ask the plan for the clinical criteria it used, in writing, free of charge.
3. Call your doctor's office and ask them to request a peer-to-peer review. Send them the denial letter the same day.
4. Put the appeal deadline on your calendar — the call does not stop that clock.
5. If the call fails, file the written appeal before the deadline, answering the exact reason in the letter.

Upload your bill and BillFighter shows which letter fits your situation, and what to do next. We're a tool, not a law firm, and this isn't legal advice. Check my bill, free →

The first no came from a checklist. Put your doctor on the phone.