Hi, it’s Tania.
Biscuit’s request for more physical therapy has been denied. The plan offers a call with a clinical reviewer, and Dr. Singh is ready to explain why the visits are needed.
“I’ll explain why he needs it, and they can change the decision,” Dr. Singh tells Sage.
Sage reaches for the scheduling instructions. “Let me check whether they can change it on this call.”
A peer-to-peer (P2P) is a clinical conversation between the treating clinician and a clinical reviewer working for the health plan or its review company. They discuss why the requested care is needed and the clinical reason for the coverage decision.
That sounds useful. But can this reviewer change the denial, or only explain it? And does the call count as an appeal, or would the office need to request one separately?
— Tania
Hey there, We’re Shivang & Tania. Each week, we write in plain English (and some sass) about how health insurance works, why claims get denied, and how patients and healthcare teams can get paid or reimbursed. If you’re new here, we recommend you start with RCM 101: How Healthcare Gets Paid, Eventually, Maybe
TL;DR
Before the doctor gets on the phone, the office needs to know what the call can actually decide. Can the reviewer change the denial, or only explain it? Prepare around the reason the care was denied, then record what the reviewer says and what happens next. Don’t assume the call counts as an appeal or buys more time to file one. Check the plan’s instructions and the applicable deadline.
We briefly introduced these calls in our prior-authorization series. This time, we follow Sage’s preparation, Dr. Singh’s conversation and Biscuit’s update to see what the office still needs to do afterward. Sage has a few things to check before anyone picks up the phone.
Biscuit would like stairs to be boring again
Biscuit is recovering from an ankle sprain, and six physical-therapy visits have helped. He can walk around the design studio more comfortably and is doing the basic exercises in his home program correctly. Stairs still give him trouble, though.
“Going up is better,” he tells Dr. Singh. “Coming down, I'm still very interested in the handrail.”
The therapist’s latest assessment helps explain why. During a step-down exercise, Biscuit still needs repeated cues and close guarding: reminders about the movement, with the therapist nearby to protect him if he loses balance. He can do the simpler home exercises on his own, but the therapist says he still needs skilled help to progress to harder tasks.
After reviewing the assessment, Dr. Singh recommends four more visits. The therapist would help Biscuit work on harder tasks, check how he responds and adjust his exercises so he can eventually continue on his own.
Reader’s note: Biscuit’s findings, visit counts and the plan’s process are fictional teaching details, not a treatment recommendation.
Rehabilitation can address strength, motion, balance and everyday function; the APTA patient guide explains why care is tailored to the individual.
The plan denies those additional visits because, in its assessment, the record does not show why Biscuit still needs supervised treatment instead of continuing the home program. Dr. Singh disagrees: being able to do the basic exercises is different from being ready to progress alone.
Sage handles billing and insurance requests for Dr. Singh’s office. She checks that the reviewer received the therapist’s report and treatment plan. Nothing is missing: the reviewer has read about Biscuit’s trouble with the step-down exercise. The disagreement is whether he needs more supervised visits.
Biscuit asks whether he should book the next appointment.
“Let us check the review options and talk with you about the care plan,” Sage says. “The additional visits haven't been approved.”
Biscuit leaves without an appointment date. Sage still needs to find out how the office can challenge the denial.
Before booking: what can this call decide?
Before booking time for Dr. Singh, Sage reads the call instructions and contacts the scheduling team.
“Can the reviewer change the denial on this call,” she asks, “or only explain why it was denied?”
The scheduling team confirms that, in this fictional case, the call offered after the denial is informational. It can explain the clinical reason for the decision, but the reviewer cannot reverse it through that discussion.
To challenge the denial, the office must request a separate formal appeal: a review of the decision through the plan’s appeal process. Booking this call does not submit that appeal or extend the deadline for it.
Before reserving Dr. Singh’s time, Sage also checks who can participate, which records the reviewer will have and how to submit the appeal.
Once she has checked the instructions, Sage goes back to Dr. Singh.
“They can explain the reason,” she says. “They can’t change the decision on this call.”
Dr. Singh pauses. “So why are we calling?”
Sage has wondered the same thing. Dr. Singh will need a reason to take time away from patients.
Sage checks the discussion's purpose before booking clinician time.
Isn't changing the decision the whole point?
The confusing part is that “peer-to-peer” describes a clinical conversation, not one standard procedure used by every plan. Some discussions can help lead to a changed decision. Others only explain a decision that has already been made.
The office needs to check the instructions for the particular call: when it happens, who can take part and whether it is part of an appeal. The American Medical Association discusses these conversations and the practical problems clinicians encounter.
For one real example, Arizona's Medicaid AHCCCS Policy 414, effective October 1, 2026, makes post-decision discussions educational, without reconsideration or changed appeal timelines. This is a rule for those Arizona Medicaid contractors, not a nationwide definition of peer-to-peer. Other plans may use the conversation differently.
For Biscuit’s request, Sage thinks the call could still help.
“They say his home program is enough,” she tells Dr. Singh. “You say he needs help with the next stage. We could ask why they reached that conclusion, then address it in the appeal.”
Dr. Singh agrees to call. In another case, the denial might already explain enough to prepare an appeal. Before booking, check whether the discussion will help and whether there is time for it before the next deadline.
Turn the records into questions
Dr. Singh starts with:
“Biscuit is better, but he still has symptoms and needs more therapy.”
Sage puts three documents together: the denial notice, the therapist’s latest assessment and the treatment plan for the requested visits. She also checks which coverage criteria the plan used and requests any criteria or explanation the office has not received.
Each document answers a different question. The denial explains why the plan said no. The assessment records what Biscuit can do and where he still needs help. The treatment plan explains what the therapist proposes to do next and why.
The plan’s scheduling instructions are separate. Sage uses those to check what the call can do, confirming anything unclear with the review team. They do not tell Dr. Singh what clinical argument to make.
“Here’s the assessment they reviewed,” Sage says, placing it beside the denial.
Dr. Singh reads them side by side. The denial says Biscuit can continue with a home program. The therapist’s assessment says he can do his current exercises independently, but still needs repeated reminders and someone close by during step-downs.
Dr. Singh writes the first question: “How did you account for the help he still needs during step-downs?”
Next comes the treatment plan. The therapist proposes reassessing Biscuit and adjusting harder exercises as he improves. These visits would not simply repeat his current home routine.
That leads to the second question: “What did you find insufficient in the explanation of why those harder exercises need a therapist?”
Dr. Singh also wants to understand how the plan applied its coverage criteria: “Which requirement do you consider unmet, and why?”
The notes give Dr. Singh something specific to ask about. Without them, the conversation would come back to “he needs more therapy,” with no explanation of why.
If the assessment does not explain what help Biscuit needs, Dr. Singh would ask the therapist to clarify before making that argument. The explanation needs to come from what the therapist observed and recommended.
Sage gathers the documents and checks the process. Dr. Singh evaluates the clinical evidence. A general resource, such as the AAOS ankle-sprain overview, can explain rehabilitation, but it cannot establish why Biscuit needs these particular visits.
The conversation
After introductions, Dr. Singh confirms the reviewer’s role and relevant expertise. They also confirm the limit Sage checked: this call can explain the denial, but changing it requires a separate appeal in this case.
Dr. Singh starts with the reason in the letter.
“The denial says Biscuit can continue with his home exercises. Is that why the four additional visits weren’t approved?”
“Yes,” the reviewer says. “The assessment shows improvement, and he can do those exercises on his own.”
“I agree with both points,” Dr. Singh says. “But the same assessment says he still needs reminders and someone close by when stepping down. How did you account for that?”
The reviewer opens that part of the assessment.
“We considered it. The decision was that an updated home program would be enough, without more supervised visits.”
The reviewer has seen the step-down findings. Dr. Singh asks why those findings did not support more visits.
“That’s the part I disagree with,” Dr. Singh says. “He can do the exercises he already knows. The therapist is recommending harder tasks, checking how he responds and adjusting them. He still needs help with those tasks.”
“So your request is for help moving beyond the current program?”
“Yes. We aren’t asking for four appointments to watch him repeat exercises he already does correctly. What did you find insufficient in the explanation of why he needs a therapist for that next step?”
“The assessment didn’t show enough reason to approve more visits. The decision was that he could manage with updated home instructions.”
“Which requirement are you applying?”
“Can you show me the section of the criteria used to deny these visits?” Dr. Singh asks. “I want to see what it requires and why you think his assessment doesn’t meet it.”
Dr. Singh asks for the document name and section, and how the office can get a copy if needed. The denial explains the plan’s conclusion; the criteria show the requirements it used to reach that conclusion. The office needs both to prepare its response.
For employer health plans covered by ERISA, Department of Labor guidance explains that a denial must include the rules or guidelines relied on, or say a free copy is available on request. A medical-necessity denial must also explain the clinical reasoning or offer that explanation free on request. Other coverage types have their own rules.
Dr. Singh notes the remaining disagreement: can Biscuit move on to harder exercises with home instructions, or does he still need the therapist’s help?
The appeal will need to connect the help Biscuit still needs during step-downs to the work proposed for the additional visits.
Dr. Singh clarifies the disagreement while Sage keeps the appeal deadline in view.
Before hanging up
Dr. Singh writes down the reviewer’s explanation before moving on.
The reviewer may point out something Dr. Singh missed. If so, Dr. Singh checks it against the records. If the reviewer says something that does not match the therapist’s notes, Dr. Singh points to the difference and asks them to explain. That gives both people a chance to check they are discussing the same information.
If the records do not answer a question, Dr. Singh says what needs to be checked with the therapist.
If the explanation on the phone differs from the written notice, keep both in the notes and ask which reason applies. Ask where that reason is documented. The team may need to address that difference in its response. If the team cannot get a clear reason, it can check the applicable review or complaint process rather than guess.
Dr. Singh summarizes before the call ends:
“So we disagree about whether he needs a therapist’s help to move on to harder exercises,” Dr. Singh says. “Our appeal will explain why we think he does, using the assessment and treatment plan. Is there another reason for the denial that we haven’t discussed?”
The reviewer confirms that this is the point to address. Dr. Singh checks where to send the written response, then ends the call.
After the call, Dr. Singh reviews the recommendation once more and still supports the additional visits. The letter will explain why Biscuit needs the therapist to check his movements, give reminders and adjust the exercises.
When requesting a letter from a clinician, make the question specific. Here, Sage can ask: “Please explain why the step-down difficulties in the assessment mean Biscuit still needs the therapist’s help.” That gives Dr. Singh a more useful starting point than “Please explain why more PT is needed.”
The letter should also acknowledge what is going well. Biscuit is doing his home program correctly, so Dr. Singh should not describe it as a failed treatment. The request concerns the harder tasks he has not yet learned to manage alone.
What Sage writes down afterward
When Dr. Singh returns the folder, Sage asks what happened.
“We went through the assessment,” Dr. Singh says. “The reviewer still thinks a home program is enough. I disagree, and we still need to appeal.”
Dr. Singh records who was on the call, which visits they discussed, the reviewer’s explanation for the denial and why Dr. Singh disagrees. Sage adds any reference number, the next step and its deadline.
Sage records that the visits remain denied and an appeal is being prepared. If a call under another plan results in a changed decision, confirm exactly what was approved and any limits before updating the patient.
She keeps the appeal on the office’s task list, with a person responsible for submitting it and a due date.
For your office: Record the decision, the next step and who will handle it before updating the patient.
Sage sends the appeal
Sage opens the appeal instructions and checks the deadline and where to send the documents. The call has not changed that deadline in this case.
First, she checks what the office needs to act on Biscuit’s behalf. This plan’s process requires paperwork authorizing the office to represent him, so she arranges for it to be completed. She checks the authorization requirements rather than assuming the office can appeal simply because Dr. Singh treats him.
Then Dr. Singh writes the clinical explanation:
“Biscuit can do his current home exercises independently. But the therapist’s assessment shows he still needs repeated reminders and someone close by during step-downs. The additional visits are for checking his response and adjusting harder exercises as he improves. That is why I recommend further supervised treatment.”
Dr. Singh points to the relevant findings in the assessment and the work described in the treatment plan. The letter explains the recommendation; those records provide the detail behind it.
Sage puts the letter, assessment and treatment plan together with the information the plan requires to identify Biscuit and the request. She checks that the appeal clearly asks the plan to review the denial of the four additional visits.
For readers doing this in their own office, follow the instructions for the patient’s appeal. Check whether the patient needs to authorize someone to act for them. HealthCare.gov explains the appeal process and representative paperwork. A practice disputing its own payment under a provider contract may have a different process.
Our earlier appeals guide walks through a patient appeal and its supporting records. The American College of Rheumatology’s guide also explains how to support an appeal with a focused letter and medical records. For the address, submission method and deadline, Sage follows this plan’s instructions.
Before sending, she checks that every document is included. Then she submits the appeal and confirms the plan received it. She saves that confirmation and sets a date to follow up.
With receipt confirmed, Sage calls Biscuit. They are waiting for the appeal decision.
Biscuit gets an update
“Are the visits approved?” Biscuit asks when Sage calls.
“Not yet. The call helped Dr. Singh understand why the reviewer disagrees. We’ve sent an appeal explaining why the therapist’s help is still needed, and the plan has confirmed it received it.”
“So we’re waiting for a decision?”
“Yes. I’ll update you on the date we agreed, even if we’re still waiting.”
Sage checks whether Biscuit has any questions. Dr. Singh’s team will advise him about his care while the appeal is pending.
This fictional case is not urgent. If waiting could harm the patient, the clinical team should address immediate care needs and check whether a faster review is available.
The call is complete. Biscuit asks when he’ll hear about the pending appeal.
Try this with your team
Use 15 minutes at your next billing huddle to practice with a fictional denial, a short clinical assessment and sample call instructions. The goal is to leave with a useful question for the reviewer and a clear plan for what happens afterward.
Check what the call can do: Ask one person to find whether the reviewer can change the decision, who may participate and whether an appeal is separate. Have them point to the instructions. This helps the team choose the right next step before reserving clinician time.
Prepare one clinical question: Ask a clinician to compare the denial reason with the assessment and explain the disagreement in one minute. Use a specific finding from the record, so the reviewer has something concrete to address.
Practice an unchanged decision: Have someone play a reviewer who explains the denial but cannot reverse it on this call. Then write the next office action. This checks whether the team knows how to continue when the conversation ends without approval.
Write the patient update: In two sentences, say whether the care is approved and what happens next. Compare that with the office’s task list. The patient should not hear “all sorted” when the team still needs to submit an appeal.
Assign the follow-up: Record who will handle the next step, its deadline and when the patient will hear from the office. Also decide what to do if the call is delayed or cancelled, so another deadline is not missed while everyone waits.
If you're the patient
You can ask the office these questions without having to prepare the clinical argument yourself:
“Are the visits approved? If not, what reason did they give?” This tells you where the request stands. Knowing the doctor spoke with a reviewer does not tell you whether the decision changed.
“Can this call change the decision, or do we need an appeal?” This helps you understand what the office is arranging and what may still need to happen afterward.
“Has the appeal been sent, and who is handling it?” If one is needed, ask whether the plan has confirmed receipt. An appeal being prepared is not yet a submitted appeal.
“Do you need a form or anything else from me, and by when?” The office may need your authorization to act for you. Knowing this early helps avoid delays.
“When will I hear from you again?” Agree on an update date, including what happens if the plan has not decided by then. Keep the denial notice and a note of the next steps.
“What should I do about my care while we wait?” Ask the clinical team. If symptoms worsen or waiting may cause harm, tell them promptly so they can assess your care needs and whether faster review is appropriate.
If a bill arrives, ask the billing office what it covers and what happens while the review is pending. A reviewer call does not automatically stop billing or establish what you owe. Keep the bill with the other paperwork.
Biscuit is still waiting for the appeal decision, and stairs still require more thought than he would like. But he knows why Dr. Singh recommends more treatment, what the office has submitted and when Sage will update him.
Have you finished a reviewer call and still wondered what to do next? Hit reply and tell us what was confusing or what helped. Please leave out patient details, medical records and identifying information.
Sources
Department of Labor: Filing a health-benefits claim — Explains denial notices and access to decision criteria for ERISA-covered employer health plans.
AHCCCS: ACOM Policy 414 — Page 1 distinguishes educational post-decision discussions from reconsideration for the specified Arizona Medicaid contractors.
AMA: Peer-to-peer discussions — Describes practical clinician-reviewer issues; proposed reforms are not universal current rights.
APTA: Ankle-sprain physical therapy — Explains individualized rehabilitation and functional goals.
AAOS: Sprained ankle — Provides clinical background on recovery and rehabilitation.
HealthCare.gov: Internal appeals — Explains member review steps, records and representative requirements.
American College of Rheumatology: Appealing a denial — Discusses focused clinical explanations and supporting documents.
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