Approvals, denials, and peer-to-peer review

Every submitted request is reviewed against the payer's own rules, and the response falls into one of three broad categories. An approval means the requested service met the plan's criteria and may proceed within stated limits. A denial means the request, as submitted, did not meet those criteria. A third, easily missed outcome is a pended or additional-information status, in which the payer neither approves nor denies but asks for records — clinical notes, imaging results, or a treatment history — before deciding. Because naming differs across payers, the same concept may appear as prior authorization, precertification, or a related label; the process that produces any of these determinations is described in the prior authorization workflow.

Approval

A determination that the requested service met the plan's criteria. It is issued for a specific service, provider, and time window and carries an authorization number.

Denial

A determination that the request did not meet the plan's criteria as submitted. It states a reason and typically explains the routes for reconsideration.

Pended / request for information

A non-final status in which the payer asks for additional documentation before deciding. It is not a denial, but requests left unanswered often become one.

An approval is only useful if its details are captured accurately, because the claim that follows has to agree with them. A typical approval specifies the authorization number, the effective date range, the approved units or visit count, the rendering provider or facility, and sometimes the place of service or a procedure category. If the billed service drifts outside those parameters — more units than approved, a date outside the window, or a different rendering provider — the claim can be denied even though an authorization exists. Reconciling the two is the subject of matching authorized units to billed services, and staying ahead of expiration is covered in tracking authorization status and deadlines.

• The authorization number and the exact service or procedure category it covers.
• Effective start and end dates, and whether the planned service falls inside that window.
• The approved quantity — units, visits, or sessions — against what is expected to be delivered.
• The rendering provider, group, or facility named on the approval.
• Any conditions, such as a required place of service or site of care.

Denials generally sort into two families. Administrative denials stem from how the request was submitted — missing documentation, incomplete references to a code set, eligibility that could not be confirmed, or provider data that did not match enrollment records. Clinical denials concern the substance of the request: reviewers concluded the service did not meet medical necessity criteria, that a required step therapy sequence was not tried first, or that a lower level of care was appropriate. A separate category is a service the plan simply does not cover, which documentation cannot change. Distinguishing the type matters because it dictates the remedy, as authorization-related denials explains in more depth.

The denial letter states the reason and the reference criteria; reading it precisely is what determines whether the fix is a corrected resubmission or a clinical challenge. General guidance on interpreting these notices appears in reading a denial.

A peer-to-peer review is a direct conversation between the clinician who ordered the service and a physician reviewer employed or contracted by the payer. Its purpose is to discuss the clinical rationale for a case that was denied, or is heading toward denial, so the reviewer can reconsider based on a fuller picture than the paperwork conveyed. Many payers offer it as a step that can precede — or sometimes substitute for — a formal written appeal, and a productive discussion may overturn the decision quickly. Availability, the window to request it, and whether it must occur before an appeal all vary by payer, plan, and case urgency.

1. 01

   Requesting the review

   The ordering practice contacts the payer within the stated window, referencing the case and the denial reason; expedited timelines may apply for urgent situations.
2. 02

   Scheduling the call

   The payer offers times for the ordering clinician — not billing staff — to speak with the reviewer.
3. 03

   Preparing the clinical case

   The clinician assembles the notes, prior treatments, and guidelines that address the specific criterion cited, following the principles in gathering clinical documentation for authorization.
4. 04

   Conducting the discussion

   The ordering clinician and the payer physician review the rationale directly; the reviewer may uphold or overturn the determination.
5. 05

   Documenting the outcome

   The practice records the result, any new authorization number, and next steps — whether the decision is favorable or an appeal is still needed.

When a determination is unfavorable, several paths remain, and the right one depends on why the request failed. An administrative denial caused by a fixable error may be corrected and resubmitted rather than appealed. A clinical denial usually calls for a peer-to-peer discussion, a formal appeal with additional evidence, or both in sequence. Separately, services delivered before authorization was obtained may fall under defined retroactive or urgent procedures that some payers allow. Each route carries its own deadline set by the payer, plan, or applicable regulation.

• Correction and resubmission — sometimes as a corrected claim — when the denial was administrative and the service still meets criteria.
• A peer-to-peer review to discuss a clinical denial directly with the payer's physician reviewer.
• A formal appeal, often filed in multiple levels, when reconsideration requires a written challenge and supporting records.
• A retroactive or urgent authorization when the service was already furnished under qualifying circumstances.