three years of appeal threads, summarised so you do not have to read them
three years of appeal threads, summarised so you do not have to read them. I have gone back and forth on this for months. Kept a log with every date, name of department and reference number. When they claimed no record of a call, I had the reference. Prior authorisation criteria are republished each plan year. A…
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.
New plan year, entirely new criteria, and the denial that had been immovable in the autumn simply did not apply in January.
That advice is jurisdiction-specific and this board spans several. Say where you are.
Yes — quoting their own policy bulletin back at them is far more effective than arguing in general terms.
deadlines run from the letter date, not from when you opened it
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
the second-level appeal is where things actually turn
Has a peer-to-peer been offered or requested?
Same view. The second-level appeal is where mine turned, after a first-level denial that looked final.
Same view.
This is the whole method. Answer the criterion they named, not the decision in general.
What exactly does the denial letter give as the reason?
External review was the thing that finally worked. I did not know it existed until a thread on this board.
What has been documented as tried, and for how long?
the diagnosis code on the claim is doing more work than anything you write
external review exists and almost nobody uses it
prior authorisation criteria change every plan year