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. The discussion 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
Service Details
Please Note: Peer to Peers are only granted for denials due to medical necessity.
Physician Information