Regence 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 medical necessity, cosmetic or investigational denial related to a pre-service, concurrent review or post-service, member liability review.
The P2P process is not for contract exclusions which do not require medical review or reimbursement issues.
A peer-to-peer is not intended to overturn a denial or replace an appeal.
Please contact our Provider Customer Service Team by phone at 1 (800) 253-0838 if you have any questions.

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 requests must be requested by the member's treating, ordering, or covering provider with knowledge of the member's condition.
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, they 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 medical necessity, cosmetic or investigational denial related to a pre-service or concurrent review or post-service, member liability review? * Pre-service requests are prior to provider services. Concurrent review is usually for a current facility stay. We send notification letters regarding post-service, member liability denials that are eligible for P2Ps. We do not offer P2P for denials of other services that have already been provided - those are handled through the appeal process.	Yes	No
2. Do you understand a P2P conversation may not always be specialty-matched? *	Yes	No
3. Do you understand that a P2P is a discussion (not an appeal) about a case to further understand the reason(s) for the denial based on our policies? A P2P is not intended to overturn a denial. * Note: New information about the service must be submitted as an appeal.	Yes	No
4. Is the provider who will be speaking with our medical director the patient's treating, ordering, or covering provider with knowledge of the patient's condition? *	Yes	No
5. Is this the first P2P you have requested for this patient and service? * Note: Additional P2Ps are ONLY allowed for new/different denial on current reviews (i.e., a request to extend an inpatient hospital stay).	Yes	No
6. Do you understand that a P2P request will not be considered if an appeal has already been submitted? * Note: 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?

Helpful information

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

Regence Medical Peer-to-Peer (P2P) Review Request Form

Question

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Member Information

Provider Information

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