Peer Review

When a Vaya Health utilization management (UM) clinician is unable to approve a request based on medical necessity or Early Periodic Screening, Diagnostic and Treatment (EPSDT), the request will be referred to a licensed doctoral psychologist or physician for peer review.

When conducting peer-to-peer reviews, peer reviewers may make at least one attempt to contact the appropriate provider representative. However, because of the tight turnaround time requirements for authorization decisions, the window to conduct peer-to-peer discussions is usually short.

If the peer reviewer is unable to reach you or does not think that a peer-to-peer conversation is necessary, Vaya will make a decision based on the information submitted with the SAR. If Vaya issues a medical necessity denial without having conducted a peer-to-peer discussion, you may request one within three business days of the denial notice.

This discussion is not an appeal of the adverse benefit determination. Rather, it is an opportunity to discuss the decision and the reasons Vaya could not approve the request. However, if based on the peer-to-peer discussion, the peer reviewer determines a different decision should have been made, Vaya may change the initial decision.