prior authorization — 22 things I got wrong before I got it right
prior authorization — 22 things I got wrong before I got it right, 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.
Documented eighteen months of what had been tried in a one-page table. That table was the appeal.
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.
Sceptical readings welcome. The confident ones are the ones I distrust.
best — the order this archive was captured in
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.
Push back: your plan is an employer plan, which changes both the appeal path and who the regulator is.
Disagreeing with this line: the deadline runs from the letter date and treating it otherwise is expensive.
Agreed on the plan-year point. Criteria that applied last year may simply not apply now.
prior authorisation criteria change every plan year
Small fix — external review is independent of the plan. The second-level internal appeal is not.
ask for the denial reason in writing, always
This. Step therapy is a paperwork requirement and it is beaten with documentation, not persuasion.
Staff name removed. Departments and criteria can be named here; individuals cannot.
Have you asked for the clinical policy bulletin by number?
Have you asked for the clinical policy bulletin by number?
This is the whole method. Answer the criterion they named, not the decision in general.
This is the whole method.
Agreed — and request the bulletin by number. They have to give it to you.
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a template letter that quotes their own criteria back is the strongest one
Same view. The second-level appeal is where mine turned, after a first-level denial that looked final.
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
External review, which is the most underused mechanism discussed on this board.
Internal appeals are decided by the plan. External review sends the determination to an independent body. Where it applies its decision binds the plan, and the deadlines to request it are short and strictly enforced.
The two things that trip people up: not knowing it exists, and exhausting the internal levels so slowly that the external window closes. Ask on the first denial what the external route is and what the deadline will be. Availability and rules vary by jurisdiction and plan type, so say where you are when you ask here.
Right, and keeping every date and reference number turns a frustrating process into an auditable one.
That advice is jurisdiction-specific and this board spans several. Say where you are.
Disagree with the tone strategy. Anger has never moved a determination; matching the criterion has.
Spent six weeks arguing in general terms and got nowhere. Two paragraphs quoting their own criteria turned it around in eleven days.
Has a peer-to-peer been offered or requested?
What exactly does the denial letter give as the reason?
What exactly does the denial letter give as the reason?
ilias_cabrera is right that this is documentation rather than persuasion. It took me a year to accept that.
appeal in writing even when they say a call is enough
- 1Have you asked for the clinical policy bulletin by number?8 comments in this branch · started by u/rekha_vestergaard
- 2That advice is jurisdiction-specific and this board spans several. Say where…7 comments in this branch · started by u/peak_area_pete