[Discussion] we are measuring appeal at the wrong time and calling it noise
we are measuring appeal at the wrong time and calling it noise — a position I have arrived at slowly and would like tested. Employer-sponsored plans may be regulated differently from individually purchased ones, which changes both the appeal route and which regulator hears a complaint. Asked for the policy bulletin…
Peer-to-peer took fifteen minutes and resolved something a written appeal had been sitting on for a month.
external review exists and almost nobody uses it
ask for the denial reason in writing, always
Added a jurisdiction tag — the answers differ completely between countries and plan types.
Added a jurisdiction tag — the answers differ completely between countries and plan types.
Adding the underused one — external review. Independent, binding where it applies, and hardly anybody gets that far.
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deadlines run from the letter date, not from when you opened it
ask for the clinical policy bulletin by number
Have you asked for the clinical policy bulletin by number?
That advice is jurisdiction-specific and this board spans several. Say where you are.
Is this a prior authorisation denial or a formulary exclusion?