What to expect when calling in for a peer-to-peer discussion:
- A peer-to-peer discussion may be initiated at any time during the authorization process by calling the same number to initiate a prior authorization request. *
- A peer-to-peer discussion may not be necessary if the requested clinical documentation is sent prior to contacting Evolent (formerly National Imaging Associates, Inc.).
- A peer-to-peer may be initiated by the office staff (non-clinical), but the case discussion must be conducted by a licensed clinician from the provider’s office.
- Ad hoc peer-to-peer discussions are available for the Advanced Imaging, Cardiac and Interventional Pain Management (IPM) programs. For these programs, plan to call a few minutes prior to licensed clinician’s availability to provide necessary member and case information.
- This information will need to be provided before the call is transferred to an appropriate clinical reviewer that is specific to the case and modality.
- Peer-to-peer discussions must be scheduled for Physical Medicine, MSK and Radiation Oncology. At least two convenient callback times will need to be provided to ensure Evolent staff is available to make the call.
- The case will then be discussed, including any additional information that may be necessary for the case to meet medical necessity. *
- Verbal clarification of clinical information from the medical records that were submitted may be discussed during the peer-to-peer. Examples include clarification of conflicting information in the notes or typographical errors.
- Any new information necessary to approve the request must be submitted in writing by uploading to RadMD.com or faxing to 1-800-784-6864 before a new determination can be made. *
- If the case cannot be approved following the peer-to-peer or with additional information; the ordering/rendering provider is asked to follow the appeal instructions provided within the denial notification.
If you would like to provide feedback regarding a peer-to-peer discussion, please contact your Evolent dedicated Provider Relations Manager.
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* This discussion may be for consultation purposes only if the re-review, reconsideration or re-open timeframe has expired or the case has a final determination and re-review, reconsideration or re-open is not available. If re-review, reconsideration or re-open is not available, providers must follow appeal instructions in the denial notification. Please confirm with the health plan if re-review, reconsideration or re-open is available.