Dagiti Tagaipaay

24-342 Follow These Guidelines When Requesting a Peer-to-Peer Review With a Medical Director to Discuss An Adverse Determination

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We strive to promote treatment that is specific to the member's condition and consistent with medical necessity, clinical practice, and appropriate level of care. An authorization request will be denied if the information provided does not meet the coverage requirements for the requested medical treatment. We will notify you and the member of the reason for the adverse determination.

You may contact us to discuss the adverse determination with a medical director (known as peer-to-peer review or P2P) using the instructions below.

Peer-to-peer reviews may not be used in certain situations

Please note, the peer-to-peer review does not apply to:

• Appeals. Once you or a member submits an appeal, you cannot request a peer-to-peer review. If the member submits the appeal for an adverse determination you have issued, we will reach out to you for any additional information you may have.
• Post-discharge. For adverse concurrent review determinations, you must request a peer-to-peer review prior to the member’s discharge. Once the member has been discharged from a facility, you cannot request a peer-to-peer review. If a member is discharged on the weekend, please call prior to discharge and leave a message for your peer-to-peer request to be considered timely. Beyond this time, an appeal may be filed.
• Initial adverse determinations beyond five business days. You have five business days to request a peer-to-peer review following issuance of an adverse prior authorization determination. Beyond this time, an appeal may be filed.

How to request a peer-to-peer review

Call the following number with the necessary information available to request a peer-to-peer review.

If you reach a voicemail, please leave a message with the required information and a callback phone number. The medical director's team will contact you to schedule a peer-to-peer review.

Additional information

Relevant sections of the Wellcare Provider Manual have been revised to reflect the information contained in this update as applicable. The manual is available online at www.wellcare.com/California/Providers/Medicare.

If you have questions regarding the information contained in this update, contact 866‑999‑3945.