Important information about peer-to-peer reviews and appeals

When we deny your request to authorize an inpatient or outpatient service, you can ask for a peer-to-peer review or you can appeal the denial.

Whether you’re requesting a peer-to-peer review or submitting an appeal, there’s important information you need to know.

Differences to be aware of

• For Medicare Advantage authorizations denied before a service or admission is provided, you can only submit an appeal. You’ll be able to talk to a Blue Cross Blue Shield of Michigan or Blue Care Network medical director during the appeal process:
• For Medicare Plus Blue^SM, you can ask to talk to a medical director anytime during the appeal process.
• For BCN Advantage^SM, you’ll have an opportunity to talk to a medical director during the panel review.
• For Medicare Advantage authorizations (either Medicare Plus Blue or BCN Advantage) denied during or after a service or admission is provided, you can either request a peer-to-peer review or submit an appeal.
• For Blue Cross or BCN commercial authorizations denied before, during or after a service or admission is provided, you can either request a peer-to-peer review or submit an appeal.

For any denied authorization, if you decide to submit an appeal, follow the appeal process outlined in the denial letter you receive.

Requesting a peer-to-peer review

• Purpose. A peer-to-peer review is a conversation between the member’s health care provider and a Blue Cross or BCN medical director about the clinical nuances of the member’s medical condition and the medical necessity of the services.
• Process. The process for submitting a request for a peer-to-peer review is outlined in the document titled How to request a peer‑to‑peer review with a Blue Cross or BCN medical director. The process differs by type of service and line of business.

We can’t accept peer-to-peer request forms about more than one member
When you request a peer-to-peer review using the Physician peer‑to‑peer request form, you must submit a separate form for each request.

We can’t accept a form that has information about more than one member. We also can’t accept a form used as a face sheet with information about different members attached to it.

When you fax a form to us, we upload it to the member’s case in the e-referral system, along with any attachments you’ve sent with it. If a form uploaded to one member’s case has information about other members on it or attached to it, it’s a violation of the Health Insurance Portability and Accountability Act.

Don’t submit clinical information after an authorization is denied
Submission of clinical information after an authorization request is denied results in the initiation of an appeal. Once that occurs, it’s no longer possible to have a peer-to-peer review, for most members.

Missed peer-to-peer reviews won’t be rescheduled
If you miss a peer-to-peer review that was scheduled with a medical director, you won’t be able to reschedule it. You’ll have to file an appeal.

How to file an appeal
When we deny an authorization request you’ve submitted, you’ll receive a letter explaining how to file an appeal.

If you want to appeal our determination, we recommend that you review the letter carefully and follow the directions about filing an appeal.

Additional information
For additional information, we encourage you to review the newsletter article we recently published:

• We’re aligning peer-to-peer review request processes for acute non-behavioral health non-elective inpatient admissions in the January 2020 issue of The Record.