help me understand external review, I have read the wiki twice
help me understand external review, I have read the wiki twice. Searched first, found three threads that contradict each other, hence the post. 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…
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.
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.
prior authorisation criteria change every plan year
Yes — quoting their own policy bulletin back at them is far more effective than arguing in general terms.
appeal in writing even when they say a call is enough
That criterion is from the previous plan year. The current bulletin has different wording.