[Discussion] external review is doing more work than we give it credit for
external review is doing more work than we give it credit for, and I am aware this is a minority view on this board.
Kept a log with every date, name of department and reference number. When they claimed no record of a call, I had the reference.
Missed a deadline because I counted from when I opened the envelope. That mistake cost me an entire cycle.
Peer-to-peer took fifteen minutes and resolved something a written appeal had been sitting on for a month.
That is everything I have. The rest is opinion and I have tried to keep it out.
best — the order this archive was captured in
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.
The process that has actually worked for people on this board, in order.
Get the denial in writing and find the criterion it names. Request the clinical policy bulletin by its number. Write the appeal against that document, criterion by criterion, attaching what has been tried and for how long. Note the deadline from the letter date and diarise it.
If the first level fails, go to the second. If the second fails, ask about external review, which is independent and, where it applies, binding. Keep every date, department and reference number as you go.
It is administrative rather than rhetorical, and the people who win are the ones who treat it that way.
Is this a prior authorisation denial or a formulary exclusion?
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
external review exists and almost nobody uses it
external review exists and almost nobody uses it
Adding the underused one — external review. Independent, binding where it applies, and hardly anybody gets that far.
a template letter that quotes their own criteria back is the strongest one
keep every date, every reference number, every name of a department
What exactly does the denial letter give as the reason?
Documented eighteen months of what had been tried in a one-page table. That table was the appeal.
Employer plan or individual plan?
Not convinced. That is a formulary exclusion rather than a prior authorisation denial, and the route to challenge it is different.
- 1external review exists and almost nobody uses it8 comments in this branch · started by u/jarno_adeyemi