Peer-to-Peer Review Requests Available Online Via Secure Provider Portal
Date: 07/14/22
This notice is to inform you that beginning October 1, 2022, Medicaid Peer-to-Peer (P2P) review requests may be submitted to MHS on the Secure Provider Portal.
The timeframe to request a P2P review is no later than 10 days after the date of denial. Online P2P review submissions will be processed the same day with a confirmation call providing the date and time scheduled. Please see the below FAQ for more information about P2P.
P2P review requests may be submitted in the following ways:
Physical Health | |
Online | Medicaid: Provider Secure Portal |
Call | Medicaid: 1-855-696-2613 |
Behavioral Health | |
Call | Medicaid: 1-800-305-3204 |
Turning Point | |
Call | Medicaid: 1-844-378-3707 |
National Imaging Associates (N.I.A.) | |
Call | Medicaid: 1-866-904-5096 |
Peer to Peer (P2P) FAQ
Q. What is a Peer-to-Peer (P2P)?
P2P calls are offered to physicians and other practitioners after a requested service has been denied. The purpose is to exchange information clinician-to-clinician.
Q. Who may perform a P2P call?
P2P calls should be performed by a clinician: (MD, DO, NP, DC or Pharmacist) who has actively participated in the care of the member. By pre-arrangement, some hospitals and systems may have a person who is employed directly by the system perform the call. Once scheduled, the MHS Medical Director or Pharmacist who made the decision will make the call to the practitioner. Contracted agencies such as Executive Health Reviews are allowed by company policy to perform this function.
Q. What is the purpose of the call?
The call is for the exchange of information. It is not an appeal. It is not uncommon for the plan not to have all the relevant information that may bear on the approval decision.
Q. Why must a P2P be scheduled no later than 10 days after a denial and completed no more than 10 days after being scheduled?
Appeals must be initiated no later than 60 calendar days after a denial. If a P2P is wanted before going to appeal, we want to make sure that there is enough time to gather supporting information.
Q. Is a call needed before appealing a case?
No. A case may be appealed anytime within 60 calendar days after the denial date. There is no requirement to perform a P2P first.
Q. If a P2P is unsuccessful may a practitioner appeal?
Yes. Legally, all appeals come from the member. However, anyone can appeal on a member’s behalf provided the member authorizes consent. Member’s consent is recognized by the verbiage included on the appeal acknowledgment letter. The member has the option to call the plan and verbally decline the appeal request. Otherwise, the appeal will be accepted as the member’s consent to be reviewed.
Q. What is the process for a P2P call?
P2Ps should be called to 1-855-696-2613. A coordinator will answer the phone and schedule a mutually agreeable time. We offer three choices of times based on Medical Director availability.
Q. Can a call be conducted immediately when called?
Yes, subject to the Medical Director’s availability. We will make every effort to get a Medical Director on the phone in real time.
Q. Can calls be scheduled over a range of times, e.g. for a half or whole day?
Yes. Many practitioners, particularly hospitalists, prefer a half day or whole day rather than a set time, e.g. Tuesday from 8 a.m. – 12 p.m. or anytime on Friday.