reading prior authorization threads from 2024 and half of it aged badly
reading prior authorization threads from 2024 and half of it aged badly, which sounds obvious until you try to state the evidence for it. 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.…
Agreed on the plan-year point. Criteria that applied last year may simply not apply now.
the diagnosis code on the claim is doing more work than anything you write
the diagnosis code on the claim is doing more work than anything you write
runa_wikstrom is right that this is documentation rather than persuasion. It took me a year to accept that.
a template letter that quotes their own criteria back is the strongest one
Missed a deadline because I counted from when I opened the envelope. That mistake cost me an entire cycle.
Employer-sponsored plans may be regulated differently from individually purchased ones, which changes both the appeal route and which regulator hears a complaint.
Cosigning on external review. It is a real mechanism, it is underused, and the deadlines are strict.
What exactly does the denial letter give as the reason?
appeal in writing even when they say a call is enough