unpopular opinion: most of what gets said here about external review is guesswork
unpopular opinion: most of what gets said here about external review is guesswork. Making the case below, and I expect to lose some of it in the comments. Appeal deadlines run from the date on the determination letter. They are strict, they are short, and a missed deadline usually forfeits that level entirely. Step…
step therapy is a documentation problem, not an argument
ask for the denial reason in writing, always
ask for the denial reason in writing, always
Agreed — and request the bulletin by number. They have to give it to you.
Agreed — and request the bulletin by number.
Adding the underused one — external review. Independent, binding where it applies, and hardly anybody gets that far.
employer plans and individual plans are different fights
That criterion is from the previous plan year. The current bulletin has different wording.
Internal appeals are decided by the plan. External review is decided by an independent body and, where it applies, its determination is binding. They are separate mechanisms and the second is chronically underused.
Push back: your plan is an employer plan, which changes both the appeal path and who the regulator is.
This. Step therapy is a paperwork requirement and it is beaten with documentation, not persuasion.
a peer-to-peer call is often faster than a written appeal
a peer-to-peer call is often faster than a written appeal
Disagreeing with this line: the deadline runs from the letter date and treating it otherwise is expensive.