the prior authorization question that gets asked weekly, answered properly
the prior authorization question that gets asked weekly, answered properly, and I am aware this is a minority view on this board. 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…
Step therapy requires documented trial of preferred alternatives. It is not an argument to be won on merits; it is a record to be produced, and the record is what the appeal must contain.
That advice is jurisdiction-specific and this board spans several. Say where you are.
document what has been tried and for how long, that is the whole case
Agreed. The denial letter tells you which criterion failed, and answering that specific criterion is the entire job.
deadlines run from the letter date, not from when you opened it
a template letter that quotes their own criteria back is the strongest one