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Single comment threadYou are looking at one branch of someone explain prior authorization to me like I have not read a paper in years — 54 comments in the full submission. View in context.
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c/insurancefights·submitted 2 years ago by u/niels_salinas

someone explain prior authorization to me like I have not read a paper in years

Discussionbranch of 6 comments

someone explain prior authorization to me like I have not read a paper in years. I would rather ask a basic question now than get this wrong quietly for two months. Asked for the policy bulletin by number and wrote the appeal against its criteria line by line. Approved on the second level after a flat first-level…

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6 comments, started 2 years ago
u/nadia_trevino65 points·2 years ago·edited

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.

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u/tidy_vialdrawer_watch-12 points·2 years ago

Employer-sponsored plans may be regulated differently from individually purchased ones, which changes both the appeal route and which regulator hears a complaint.

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u/RetaAndRegret21 point·2 years ago

ask for the clinical policy bulletin by number

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u/vito_beaulieu1 point·2 years ago

Small fix — external review is independent of the plan. The second-level internal appeal is not.

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u/liv_vukovic1 point·2 years ago·edited

Small fix — external review is independent of the plan.

Adding the underused one — external review. Independent, binding where it applies, and hardly anybody gets that far.

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u/controversial_only34 points·2 years ago

Push back: your plan is an employer plan, which changes both the appeal path and who the regulator is.

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The paperwork war. Prior-authorisation criteria, denial reason codes, step-therapy documentation, external review, employer carve-outs, and the appeal letter templates the community has iterated on for three years. Mostly US-shaped but the tactics generalise.

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