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c/insurancefights·submitted 2 months ago by u/janoshik_junkie

the denial question that gets asked weekly, answered properly

Deniedbranch of 7 comments

the denial question that gets asked weekly, answered properly, and I am aware this is a minority view on this board. The process that has actually worked for people on this board, in order. Get the denial in writing and find the criterion it names. Request the clinical policy bulletin by its number. Write the appeal…

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7 comments, started 2 months ago
u/purity_pedantanalytical0 points·2 months ago

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.

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u/marisol_moreau1 point·2 months ago

Disagree with the tone strategy. Anger has never moved a determination; matching the criterion has.

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u/janoshik_junkieOPindependent tester1 point·2 months ago·edited

Small fix — external review is independent of the plan. The second-level internal appeal is not.

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[deleted]1 point·2 months ago

[deleted]

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u/wholesome_lurker1 point·2 months ago

the diagnosis code on the claim is doing more work than anything you write

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u/hassan_chowdhury1 point·2 months ago

Disagree with the tone strategy.

Adding the underused one — external review. Independent, binding where it applies, and hardly anybody gets that far.

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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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