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c/insurancefights·submitted 1 months ago by u/RetaAndRegret2

the prior authorization question that gets asked weekly, answered properly

Templatebranch of 11 comments

Quick one. Canada here. prior authorization works very differently where I live than in the threads that dominate the front page, and I keep seeing people confidently given advice that simply does not apply outside the US. Specifics: the route I used took 15 weeks and cost roughly what I expected. The admin was worse…

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11 comments, started 1 months ago
u/gustav_vermeulen79 points·1 months ago

What was the denial code?

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u/camila_vasquez0 points·1 months ago

resubmission after denial requires new documentation

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u/kasper_cabrera1 point·1 months ago

resubmission after denial requires new documentation

Disagree on that part. 96.8% and 96.2% on the same vial is normal.

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u/line_bergstrom63 points·1 months ago·edited

This is the "correlation is mechanism" thing again. You changed three variables at once.

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u/RetaAndRegret2OP41 points·1 months ago·edited

Poland plan: step therapy required 20 medications first. Did them all, got approval. The order matters.

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u/RetaAndRegret2OP21 points·1 months ago

copay is separate from coverage

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u/runa_wikstrom64 points·1 months ago

step therapy documentation is the weapon, use it

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u/solene_eriksen17 points·1 months ago

Copay was formulary for the copay then another 2% of the total. Read the actual plan document.

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u/formulary_fighterappeals8 points·1 months ago

Sceptical. If this were true we would see it reflected in the data and we do not.

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u/sock_puppet_spotter6 points·1 months ago

external review is the appeal after insurance says no

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u/kian_ferreira2 points·1 months ago

This is correct. Appeal letters work.

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About c/insurancefights

The paperwork war. Prior-authorisation criteria, denial reason codes, step-therapy documentation, external review, employer carve-outs, and the appeal letter templates the community has iterated on for three years. Mostly US-shaped but the tactics generalise.

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