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Peer-to-Peer Review

Meaning

Peer-to-peer review, in the context of clinical practice and insurance, is a formal process where a health insurance provider’s physician or clinical reviewer communicates directly with the prescribing or treating clinician to discuss the medical necessity of a requested service or treatment. This process is often initiated following a preliminary coverage denial or prior authorization request that did not meet the insurer’s initial criteria. It serves as a clinical dialogue to justify the proposed treatment based on the patient’s unique physiological needs and the latest medical evidence.