Utilization Review

Peer Review Prep Tool

Pick the denial focus, level of care, payer, and call type. Add chart-based details and review anticipated questions with a one-page talking-point outline.

Clinical details are your words, no PHI. Runs entirely in your browser. Nothing you type is sent or saved server-side.

Call setup

Drafts autosave to this browser only. Do not paste patient-identifying information (names, DOB, full MRN, member numbers).

Denial reason the reviewer will likely focus onLevel of care at issuePayer trackCall type

Clinical details (optional)

Your words, no PHI. Examples are illustrative only — replace with your phrasing. Blank fields become[ADD: …] prompts in the outline.

One-sentence patient summary (clinical only, no name/DOB)Current risk factors / safety concernsRecent clinical events (last 7–30 days)Withdrawal / physiologic findings (cite by date if relevant)Co-occurring conditions raising intensityFunctional impairment / inability to maintain at lower LOCDocumented response to treatment so farStep-down plan and criteria the team will useSpecific risks of premature step-down / denialThe explicit ask (what you want authorized)

Drafts autosave to this browser as you type.

Anticipated reviewer questions

Pre-call drafting aid only — not medical or legal advice.

Anticipated reviewer questions
Denial focus: Medical necessity not established at requested level of care
Level of care: Residential / inpatient SUD

1. Walk me through why the chart supports Residential / inpatient SUD rather than the next lower level of care.
   Your answer: [JOT 1–2 SENTENCES, CITE CHART BY DATE]

2. What are the contemporaneous objective findings — vitals, withdrawal score from your chart, behavioral observations — that establish this acuity?
   Your answer: [JOT 1–2 SENTENCES, CITE CHART BY DATE]

3. What clinical criteria did your program use, and what did the most recent assessment document?
   Your answer: [JOT 1–2 SENTENCES, CITE CHART BY DATE]

4. What’s the specific clinical risk if we authorize a lower level of care instead?
   Your answer: [JOT 1–2 SENTENCES, CITE CHART BY DATE]

5. If you uphold the denial, can you state the specific criterion and the rule, guideline, or protocol you relied on, and confirm the next-level appeal timeline?
   Your answer: [JOT 1–2 SENTENCES, CITE CHART BY DATE]

Reminder: ask the reviewer to state the criterion they’re applying and to point you to the rule or guideline relied upon — you have the right to it.

Talking-point outline

Pre-call drafting aid only — not medical or legal advice.

PEER-TO-PEER TALKING-POINT OUTLINE
Call type: Pre-denial P2P (before final adverse determination)
Level of care at issue: Residential / inpatient SUD
Denial focus: Medical necessity not established at requested level of care
Case label (no PHI): [CASE-FAKE-123]
Dates of service at issue: [MM/DD/YYYY – MM/DD/YYYY]

1. OPENING (15 seconds — say first, on the record).
  - One-sentence patient summary: [ADD: one-sentence patient summary]
  - Explicit ask (what you want authorized): [ADD: explicit ask (what you want authorized)]

2. WHY THE REQUESTED LEVEL OF CARE IS THE APPROPRIATE SETTING NOW.
  - Frame: keep this behaviorally specific, date-anchored, and tied to the chart. Avoid conclusory labels.
  - Current risk factors / safety concerns: [ADD: current risk factors / safety concerns]
  - Recent clinical events (last 7–30 days): [ADD: recent clinical events (last 7–30 days)]
  - Withdrawal / physiologic findings: [ADD: withdrawal / physiologic findings]
  - Co-occurring conditions raising intensity: [ADD: co-occurring conditions raising intensity]
  - Functional impairment / lower-LOC inadequacy: [ADD: functional impairment / lower-loc inadequacy]

3. TREATMENT RESPONSE SO FAR.
  - Frame: what active, skilled clinical work has happened and what has changed because of it. This is where custodial-vs-active questions are won.
  - Documented response to treatment: [ADD: documented response to treatment]
  - [INSERT: most recent treatment-plan adjustment and the clinical reasoning behind it, with date and clinician]

4. LESS-RESTRICTIVE-ALTERNATIVE ANALYSIS.
  - Frame: why a lower level of care won’t safely meet these needs at this time. Address each lower LOC the reviewer might suggest.
  - [INSERT: prior lower-LOC trials (program, dates, outcomes) OR specific clinical reasons a lower setting would be unsafe now]

5. STEP-DOWN PLAN AND CRITERIA.
  - Frame: show the reviewer you have a concrete off-ramp. Reviewers grant continued stay more readily when they see a clear exit.
  - Step-down plan and criteria the team will use: [ADD: step-down plan and criteria the team will use]

6. RISKS OF PREMATURE STEP-DOWN / DENIAL.
  - Frame: name the specific, foreseeable harm. Quantify where possible.
  - Specific risks if denied or stepped down too early: [ADD: specific risks if denied or stepped down too early]

7. CLOSING (last 60 seconds — say before you hang up).
  - Restate the explicit ask.
  - Ask the reviewer to state on the record the criterion they’re applying and the rule, guideline, or protocol relied upon.
  - If upheld, ask for: the specific clinical rationale, the reviewer’s credentials, and instructions and deadlines for the next level of appeal.
  - Confirm whether anything else from the chart would change the decision before it’s finalized.

8. 42 CFR PART 2 — verbal disclosure check.
  - Before discussing identifiable SUD treatment information with the payer reviewer, confirm a valid Part 2 consent (or applicable exception) is on file. Note redisclosure is prohibited except as permitted by 42 CFR Part 2.

— — —
APPLICABLE APPEAL RIGHTS (for your reference, not a script for the call):
  If the determination is upheld, the member has the right to a full and fair review and the specific clinical rationale and any guideline relied upon, free of charge, under 29 CFR 2560.503-1; external/independent review is available under 45 CFR 147.136.

This tool produces a pre-call preparation outline and a list of anticipated reviewer questions based on the categories you select. It is general information, not medical or legal advice. You are responsible for the clinical accuracy of anything you add, for handling patient-identifying information appropriately under HIPAA and 42 CFR Part 2 (including confirming consent before verbally disclosing SUD treatment information to a payer reviewer), and for following your licensing board, program policies, and applicable appeal procedures. The tool does not reproduce ASAM Criteria, MCG, InterQual, or any payer's medical policy; cite your own program's contemporaneous chart findings and ask the reviewer to state the criterion they're applying. Drafts autosave to this browser only; nothing is sent anywhere.