[Discussion] the copay advice in here is 2 years out of date
the copay advice in here is 2 years out of date. Change my mind, genuinely — I have no stake in being right about this.
The numbers the title promised, since a headline without them is worthless: 2 years. Everything below is context for those.
Appeal deadlines run from the date on the determination letter. They are strict, they are short, and a missed deadline usually forfeits that level entirely.
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.
That is everything I have. The rest is opinion and I have tried to keep it out.
best — the order this archive was captured in
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.
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.
Kept a log with every date, name of department and reference number. When they claimed no record of a call, I had the reference.
Careful — the deadline runs from the date on the letter. Waiting for a call back can cost you the appeal entirely.
External review was the thing that finally worked. I did not know it existed until a thread on this board.
Employer-sponsored plans may be regulated differently from individually purchased ones, which changes both the appeal route and which regulator hears a complaint.
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
Is this a prior authorisation denial or a formulary exclusion?
Push back: your plan is an employer plan, which changes both the appeal path and who the regulator is.
Small fix — external review is independent of the plan. The second-level internal appeal is not.
Member and policy numbers redacted from the screenshot above. Everything else left as posted.
Disagree with the tone strategy. Anger has never moved a determination; matching the criterion has.
That advice is jurisdiction-specific and this board spans several. Say where you are.
a peer-to-peer call is often faster than a written appeal
the diagnosis code on the claim is doing more work than anything you write
the formulary is published, read it before you appeal
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.
Spent six weeks arguing in general terms and got nowhere. Two paragraphs quoting their own criteria turned it around in eleven days.
A denial letter is required to state a reason and to reference the criterion applied. That reference is the handle: request the clinical policy document by its identifier and answer it point by point.
Agreed on the plan-year point. Criteria that applied last year may simply not apply now.
Agreed on the plan-year point.
Disagreeing with this line: the deadline runs from the letter date and treating it otherwise is expensive.
Peer-to-peer took fifteen minutes and resolved something a written appeal had been sitting on for a month.
Documented eighteen months of what had been tried in a one-page table. That table was the appeal.
That criterion is from the previous plan year. The current bulletin has different wording.
Correcting myself upthread: the deadline was 10 days, not the figure I gave.
the denial letter names the criterion, start there
Missed a deadline because I counted from when I opened the envelope. That mistake cost me an entire cycle.
Missed a deadline because I counted from when I opened the envelope.
elin_varga is right that this is documentation rather than persuasion. It took me a year to accept that.
I would not skip the peer-to-peer. It is often the fastest route and it costs a phone call.
- 1A denial letter is required to state a reason and to reference the criterion…10 comments in this branch · started by u/ismael_nwosu
- 2Member and policy numbers redacted from the screenshot above. Everything…6 comments in this branch · started by u/appeal_letter_al