why does nobody talk about denial
Question in the title, detail here: why does nobody talk about denial. New plan year, entirely new criteria, and the denial that had been immovable in the autumn simply did not apply in January. The process that has actually worked for people on this board, in order. Get the denial in writing and find the criterion…
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.
prior authorisation criteria change every plan year
prior authorisation criteria change every plan year
hplc_hobbyist is right that this is documentation rather than persuasion. It took me a year to accept that.
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
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.
Employer-sponsored plans may be regulated differently from individually purchased ones, which changes both the appeal route and which regulator hears a complaint.
I would not skip the peer-to-peer. It is often the fastest route and it costs a phone call.