unpopular opinion: most of what gets said here about external review is guesswork
unpopular opinion: most of what gets said here about external review is guesswork. Making the case below, and I expect to lose some of it in the comments.
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.
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.
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.
Happy to answer the boring questions. Those are usually the ones worth asking.
best — the order this archive was captured in
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.
Careful — the deadline runs from the date on the letter. Waiting for a call back can cost you the appeal entirely.
Left up. It carries dates, a criterion and an outcome, which is what makes these threads useful.
Yes. Written, always, even when they tell you a phone call is sufficient.
New plan year, entirely new criteria, and the denial that had been immovable in the autumn simply did not apply in January.
What exactly does the denial letter give as the reason?
step therapy is a documentation problem, not an argument
ask for the denial reason in writing, always
ask for the denial reason in writing, always
Agreed — and request the bulletin by number. They have to give it to you.
Agreed — and request the bulletin by number.
Adding the underused one — external review. Independent, binding where it applies, and hardly anybody gets that far.
employer plans and individual plans are different fights
That criterion is from the previous plan year. The current bulletin has different wording.
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.
Push back: your plan is an employer plan, which changes both the appeal path and who the regulator is.
This. Step therapy is a paperwork requirement and it is beaten with documentation, not persuasion.
a peer-to-peer call is often faster than a written appeal
a peer-to-peer call is often faster than a written appeal
Disagreeing with this line: the deadline runs from the letter date and treating it otherwise is expensive.
keep every date, every reference number, every name of a department
the denial letter names the criterion, start there
Yes — quoting their own policy bulletin back at them is far more effective than arguing in general terms.
the denial letter names the criterion, start there
This is the whole method. Answer the criterion they named, not the decision in general.
Have you asked for the clinical policy bulletin by number?
deadlines run from the letter date, not from when you opened it
- 1step therapy is a documentation problem, not an argument12 comments in this branch · started by u/saskia_lokken
- 2keep every date, every reference number, every name of a department6 comments in this branch · started by u/cardio_endpoint_c