The Blue Cross and Blue Shield of North Carolina (Blue Cross NC) Commercial Utilization Management (UM) team would like to provide updated information and instruction to providers for when Peer-to-Peer physician consults are requested related to the denial of prior authorization (PA) services for Commercial lines of business – Fully Insured, ASO and State Health Plan.

Key points:

• The Blue Cross NC policy for the Peer-to-Peer consult process is designed in accordance with National Committee for Quality Assurance (NCQA) requirements to allow servicing providers the opportunity to have clinical discussion between the servicing provider and a Blue Cross NC Medical Director.
• The purpose of the Peer-to-Peer consult is to give servicing providers an opportunity to discuss the rationale for denial of the requested service; the Peer-to-Peer consult is not intended to be used as a reconsideration to overturn the denial decision.
• To obtain a reconsideration of the denial decision, a provider would need to request a formal reconsideration via the Provider Courtesy Review (PCR) process, as noted here:
  • If requesting a reconsideration when scheduling a Peer-to-Peer consult, the provider is asked to make this known to the scheduler, which will begin the official PCR process.
  • If a reconsideration has been requested and the outcome of the Peer-to-Peer consult is to uphold the initial denial, the provider retains additional appeal rights as outlined in the denial letter.
  • For Emergent cases where a reconsideration is requested, a Blue Cross NC Utilization Management (UM) nurse reviewer will conduct a preliminary assessment of new clinical within two days of the request. If the request can be approved at the nurse level, the Peer-to-Peer consult will be cancelled, otherwise, the Peer-to-Peer consult will proceed as scheduled.
  • For elective cases where a reconsideration is requested, the provider must submit additional documentation for reconsideration prior to the Peer-to-Peer, which will then be reviewed by the UM nurse. If the UM nurse is unable to overturn the initial denial, the Peer-to-Peer consult will proceed.
• Notes: 
  • Additional clinical information that addresses the rationale for denial must be submitted by the provider prior to a Peer-to-Peer consult being scheduled. 
  • Peer-to-Peers are scheduled in the order they are received and are scheduled with the same Blue Cross NC Medical Director that issued the initial denial decision.