These answers draw in part from “Navigating the Peer Review Process – Lessons Learned from Dating” by Alexandra Tomei, M.Ed., BCBA, LBA (TX), LSSWB (BehaviorLive), and extend it with peer-reviewed research from our library of 27,900+ ABA research articles. Clinical framing, BACB ethics code references, and cross-links below are synthesized by Behaviorist Book Club.
View the original presentation →A peer review typically begins when a clinical reviewer examines your authorization request or progress documentation and identifies questions or concerns about the medical necessity of the requested services. This may trigger a written request for additional information or a scheduled phone call between you and the reviewer. During a peer-to-peer call, the reviewer will ask questions about the client's diagnosis, functional assessment results, treatment goals, progress data, and the rationale for the requested service intensity. You will have the opportunity to present your clinical case and respond to specific concerns. The reviewer then makes an authorization decision based on the information provided and the payer's medical necessity criteria.
Preparation should include reviewing the payer's medical necessity criteria to understand what the reviewer will be evaluating, organizing your assessment data and progress reports for quick reference during the call, preparing a concise summary of your three to four strongest arguments for the requested authorization, anticipating questions the reviewer might ask based on common areas of scrutiny, and confirming that your documentation is complete and supports the clinical picture you will present. Practice articulating your key points clearly and concisely, as review calls are typically time-limited. Prepare specific data points rather than relying on general impressions about client progress or need.
Common reasons include insufficient documentation of current functional deficits, progress data that suggests the client may have met goals that have not been updated, treatment plans that do not clearly connect authorized hours to specific treatment activities, lack of data demonstrating why the current intensity level is still needed, goals that appear to overlap or lack clear functional significance, insufficient evidence of parent or caregiver training as a treatment component, and documentation that uses excessive jargon without clear explanation. Addressing these issues proactively in your documentation and during the review conversation significantly reduces the likelihood of adverse outcomes.
Effective advocacy is assertive without being aggressive. Present your clinical data confidently and clearly. When you disagree with the reviewer's perspective, acknowledge their point before presenting your counter-argument. Use data rather than emotion to support your position. Ask clarifying questions when you do not understand the reviewer's concern. Frame your advocacy in terms of the client's functional outcomes rather than simply requesting a specific number of hours. If you feel frustrated, pause and refocus on the clinical facts. Maintaining a professional, collaborative tone throughout the interaction is both ethically required and strategically effective.
First, request the denial in writing with the specific rationale for the decision. Review the denial carefully against the payer's medical necessity criteria to identify whether the issue is clinical, documentation-based, or procedural. Determine the available appeal pathways and timelines, as most payers have formal appeal processes with specific deadlines. Prepare a comprehensive appeal that addresses each specific reason cited in the denial, including additional supporting documentation where needed. Consider whether an external review or regulatory complaint is warranted. Throughout this process, continue to provide services to the extent possible and document any negative clinical impacts of the reduced authorization.
Code 2.01 requires you to provide effective treatment, which includes securing the authorization needed to implement your treatment plan at the recommended intensity. Code 3.08 establishes your primary responsibility to the client even when services are funded by a third party. Code 3.12 specifically requires advocacy for appropriate services and resources. Together, these codes create an ethical obligation not only to design effective treatment plans but to navigate the systems that fund those plans effectively. A behavior analyst who writes an excellent treatment plan but cannot communicate its necessity to a peer reviewer is failing to fulfill the full scope of their ethical responsibilities.
Start by acknowledging the reviewer's role and expressing genuine willingness to provide whatever information they need to make an informed decision. Ask what specific areas they would like to focus on rather than launching into a rehearsed presentation. Listen actively to their questions and respond directly rather than deflecting or providing tangential information. Use professional language that bridges behavioral terminology and the reviewer's likely clinical framework. If the reviewer asks a question you cannot answer immediately, acknowledge it honestly and offer to follow up. Thank the reviewer for their time. These relational behaviors build trust and establish you as a credible, collaborative professional.
Documentation should tell a clear clinical story: this is where the client started, this is where they are now, this is where they need to go, and this is what it takes to get there. Include quantitative baseline data for all treatment goals. Provide graphic displays of progress data with clear trend lines. Connect each treatment goal to functional outcomes that matter for the client's daily life. Specify how authorized hours are allocated across treatment activities. Document medical necessity rationale explicitly rather than relying on reviewers to infer it. Use clear, accessible language that a reviewer from any clinical background can understand. Update goals promptly when criteria are met to avoid the appearance of maintenance without justification.
This is common and requires the ability to translate behavioral concepts into language the reviewer can understand. Instead of describing a schedule of reinforcement, explain the specific teaching strategy and why it requires the frequency of sessions you are requesting. Instead of citing behavioral terminology for a skill domain, describe the functional impact on the client's daily life. Avoid jargon that might confuse the reviewer or create the impression that you are trying to obscure simple concepts with technical language. Be prepared to educate briefly about behavioral principles when relevant, framing your explanation as collaborative information sharing rather than lecturing.
Frustration during peer reviews is a natural response to a process that can feel arbitrary or adversarial. When you notice frustration building, focus on what you can control: the clarity of your communication, the quality of your data, and the professionalism of your demeanor. Take a brief pause before responding to a question that triggers a strong reaction. Remind yourself that the reviewer is operating within a system with its own constraints and pressures. Channel frustration into preparation: after the call, document what triggered the frustration and develop a strategy for handling that situation more effectively next time. If the outcome feels genuinely unjust, pursue formal appeal channels rather than expressing frustration during the call.
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All behavior-analytic intervention is individualized. The information on this page is for educational purposes and does not constitute clinical advice. Treatment decisions should be informed by the best available published research, individualized assessment, and obtained with the informed consent of the client or their legal guardian. Behavior analysts are responsible for practicing within the boundaries of their competence and adhering to the BACB Ethics Code for Behavior Analysts.