[Question] how do you actually verify copay
Genuine question, and the title is the question: how do you actually verify copay. Spent six weeks arguing in general terms and got nowhere. Two paragraphs quoting their own criteria turned it around in eleven days. Asked for the policy bulletin by number and wrote the appeal against its criteria line by line.…
Employer-sponsored plans may be regulated differently from individually purchased ones, which changes both the appeal route and which regulator hears a complaint.
Not convinced. That is a formulary exclusion rather than a prior authorisation denial, and the route to challenge it is different.
the denial letter names the criterion, start there
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That criterion is from the previous plan year. The current bulletin has different wording.
Same view. The second-level appeal is where mine turned, after a first-level denial that looked final.
Small fix — external review is independent of the plan. The second-level internal appeal is not.
What is the appeal deadline on the letter?