[Discussion] the denial advice in here is 3 years out of date
the denial advice in here is 3 years out of date, and I am aware this is a minority view on this board.
3 years — those are the numbers, and they are the ones I am willing to defend.
Missed a deadline because I counted from when I opened the envelope. That mistake cost me an entire cycle.
Peer-to-peer took fifteen minutes and resolved something a written appeal had been sitting on for a month.
I will update this if the picture changes rather than quietly leaving it up.
best — the order this archive was captured in
Staff name removed. Departments and criteria can be named here; individuals cannot.
employer plans and individual plans are different fights
employer plans and individual plans are different fights
nnt_nate is right that this is documentation rather than persuasion. It took me a year to accept that.
A peer-to-peer conversation puts the prescribing clinician in front of a reviewing clinician. It bypasses the correspondence cycle entirely and is often the fastest available route.
Kept a log with every date, name of department and reference number. When they claimed no record of a call, I had the reference.
Kept a log with every date, name of department and reference number.
Disagreeing with this line: the deadline runs from the letter date and treating it otherwise is expensive.
External review was the thing that finally worked. I did not know it existed until a thread on this board.
external review exists and almost nobody uses it
prior authorisation criteria change every plan year
ask for the denial reason in writing, always
a template letter that quotes their own criteria back is the strongest one
Prior authorisation criteria are republished each plan year. A criterion that blocked you in one year may not exist in the next, so a denial is worth retesting after the turnover.
Disagree with the tone strategy. Anger has never moved a determination; matching the criterion has.
ask for the denial reason in writing, always
Agreed — and request the bulletin by number. They have to give it to you.
Yes. Written, always, even when they tell you a phone call is sufficient.
Yes — quoting their own policy bulletin back at them is far more effective than arguing in general terms.
Cosigning on external review. It is a real mechanism, it is underused, and the deadlines are strict.
- 1ask for the denial reason in writing, always6 comments in this branch · started by u/saskia_lokken