Peer To Peer Request | Medical Forms Resource Center

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Peer to Peer Discussion Request Form

Peer to Peer Discussions are offered for medical necessity adverse decisions. These discussions are not routinely available for contract exclusion and benefit exhaust denials; as a result contract exclusion and benefit exhaust denials cannot be resolved at this level. After the completed form is returned, a discussion between the treating MD and the Healthplan Medical Director. This discussion should occur within 2 business days for Concurrent cases, 5 business days for Pre-Service cases and should focus on NEW clinical information related to medical necessity. Using the information provided on this form, two attempts will be made to contact the provider based on the availability listed below. This discussion should occur between a BlueCross BlueShield of South Carolina/BlueChoice HealthPlan of South Carolina Medical Director and the treating physician. Please submit additional information needed to help render the decision. To guarantee prompt response, ensure that this form is completed in its entirety and submitted with new clinical information. Incomplete forms will not be considered for a peer to peer discussion.

Please note: This is not an appeal.
For appeal rights the member should refer to the Member Service number on the back of their card.

Instructions:

Fields marked with an asterisk are required. All requests are subject to review. Please print your request at the end of the submission process for your records.

Patient Information

Patient First Name

Patient Middle Initial

Patient Last Name

ID Card Number

Date of Birth

Service Details

CPT Code(s) Denied Please Note: Peer to Peers are only granted for denials due to medical necessity.

Please state why the denial should be overturned Peer to Peer discussions are not routinely available for cases reviewed by Appeals, or cases denied for contract exclusion and benefit exhaust denial. These cases cannot be resolved through the Peer to Peer process.

Physician Information

Physician's First Name

Physician's Last Name

Preferred Number

Area Code First Three Digits Last Four Digits

Fax

Area Code First Three Digits Last Four Digits

Are there any special instructions to reach Physician/Staff? VRU instructions - The contact number should be a number that will be answered during business hours. i.e., Representative, Nurse’s or assistant's number who can retrieve the Physician. The plan will make two attempts on date selected within the requested window at the number provided.

Date Note: if no date is specified call will be made in 1 business day.

I acknowledge that the Physician has been notified that a Peer to Peer request is being submitted. You should not submit this form until you can attest to the above.

Provide new clinical ddocumentation by sending a secure e-mail to mailto:Peer.Medical@BCBSSC.com.