Asuris Northwest Health Medical Peer-to-Peer (P2P) Review Request Form

Purpose of the Peer-to-Peer (P2P)

  • Use this form to request a peer-to-peer review (P2P) of a behavioral or non-behavioral healthcare denial determination resulting from a Medical Necessity Review requiring consideration of the memberís circumstances relative to appropriate clinical criteria and our policies.
  • The P2P process is not for discussions related to contract exclusions, always investigational determinations, or denials based on clinical edits.
  • Other channels of communication are available for circumstances that fall outside of the P2P process. These include the options outlined below.
    • Reimbursement policies - may complete the Reimbursement Policy Feedback Form (located on our Provider website).
    • Medical policies - may complete the Medical Policy Comment Form (located on our Provider website)
    • Customer Service: Please contact our Provider Customer Service Team by phone at 1 (800) 253-0838 if you have any questions.
    • Appeals Process: If the request does not meet these criteria and you wish to submit an appeal, please refer to the denial letter.
  • A peer-to-peer is not intended to overturn a denial or replace an appeal.

Criteria for Request

  • This form must be submitted within 15 calendar days of the date on the denial letter.
  • For non-Medicare members, a P2P request will not be accepted if an appeal has already been submitted.
  • P2P request must be requested by the memberís treating, ordering, or covering provider with knowledge of the memberís condition. Provider types that are considered peers for the P2P process include MD, DO, PA, or other Doctoral degrees.
  • If the answers to all the questions below are yes, a P2P may be conducted.


If you would like to request a P2P to discuss the denial of a physician-administered medication, please submit the Pharmacy Peer-to-Peer Review Request Form.

  • Please note that all medication-related calls will be routed to a Regence clinical pharmacist. If there are questions that the clinical pharmacist is unable to answer, the team will schedule a call with a Regence Medical Director.

If the request does not meet these criteria and you wish to submit an appeal, please refer to the denial letter.


Fields marked with an asterisk (*) are required fields.

Question

Yes

No

1. Is this request for a review that required consideration of the memberís circumstances and is it related to a pre-service or concurrent review? *

  • Always investigational denials are not eligible for P2P
  • Contract exclusion denials are not eligible for P2P
  • Denials based on Clinical Edits are not eligible for P2P
Yes No
2. Do you understand a P2P conversation may not always be specialty-matched? * Yes No
3. Is the provider who will be speaking with our Medical Director an eligible Peer (MD, DO, PA, or other Doctoral degree) and the patientís treating, ordering, or covering provider with knowledge of the patientís condition. *

Ineligible providers for P2P discussions include DME providers, Audiologists, Labs, Third Party Vendors, etc.

Yes No
4. Is this the first P2P you have requested for this patient and service? *

Additional P2Ps are ONLY allowed for new/different denial on current reviews (i.e. a request to extend an inpatient hospital stay).

Yes No
5. Do you understand that a P2P request will not be considered if an appeal has already been submitted? *

P2P requests for Medicare members will be considered regardless of whether an appeal has been submitted or not.

Yes No

Member Information

Member last name:*
Member middle name:
Member first name:*
Member ID number:*
Medicare member?* Yes No
Date of birth (mm/dd/yyyy):*
Reference or claim number (found on denial letter):
Service for P2P discussion:

Provider Information

Please enter your contact information for this P2P request
First name and last initial of individual submitting this form:*
Office or direct phone number for coordination:*
Does this number have a secure and confidential voice mail?* Yes No
Please provide a secure email address for P2P confirmation:
Provider last name:*
Provider first name:*
Provider NPI/Tax ID:*
Preferred provider phone number for P2P call (pager numbers not accepted):*
Does this number have a secure and confidential voice mail?* Yes No
Are there any special phone instructions to reach the attending/covering physician?

Provider Availability

Please read requirements carefully
Provide at least two different call windows following these guidelines:
  • At least 48 hours (two business days) from submitting this form.
    • If the request is in regards to an inpatient service denial and the patient is currently in a facility, we try to accommodate a discussion within 24 hours of the initial request.
  • Hours available:
    • Monday - Thursday 8:00 am - 4:00 pm Pacific Time
    • Friday 8:00 am - 12:00 pm Pacific Time
If we have any questions or a need to reschedule the time periods you indicated, we will select 2 call windows to contact you using the preferred physician's phone number provided.

If we have not been able to reach you in 2 of the call times provided, the peer-to-peer conversation will be considered completed and you may pursue the appeal process as applicable.
Date Call Window
All times in Pacific time zone
Additional Instructions

(e.g. ok to leave message, ask for specific person)

8:00 am - 9:00 am
9:00 am - 10:00 am
10:00 am - 11:00 am
11:00 am - 12:00 pm
1:00 pm - 2:00 pm (Mon-Thur only)
2:00 pm - 3:00 pm (Mon-Thur only)
3:00 pm - 4:00 pm (Mon-Thur only)
8:00 am - 9:00 am
9:00 am - 10:00 am
10:00 am - 11:00 am
11:00 am - 12:00 pm
1:00 pm - 2:00 pm (Mon-Thur only)
2:00 pm - 3:00 pm (Mon-Thur only)
3:00 pm - 4:00 pm (Mon-Thur only)
8:00 am - 9:00 am
9:00 am - 10:00 am
10:00 am - 11:00 am
11:00 am - 12:00 pm
1:00 pm - 2:00 pm (Mon-Thur only)
2:00 pm - 3:00 pm (Mon-Thur only)
3:00 pm - 4:00 pm (Mon-Thur only)

Helpful information

  • Provider Customer Service: 1 (800) 253-0838
  • Medicare Customer Service: 1 (866) 749-0355