Blue Cross and Blue Shield of North Carolina Provides Guidance for Commercial Peer-to-Peer Physician Consults

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.