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c/insurancefights·submitted 2 months ago by u/cardio_endpoint_c

prior authorization — 22 things I got wrong before I got it right

Deniedbranch of 8 comments

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…

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8 comments, started 2 months ago
u/rekha_vestergaard74 points·2 months ago

Have you asked for the clinical policy bulletin by number?

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u/milan_wikstrom52 points·2 months ago

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.

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u/adaeze_weiss39 points·2 months ago

This is the whole method.

Agreed — and request the bulletin by number. They have to give it to you.

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[deleted]32 points·2 months ago

[deleted]

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u/purity_pedantanalytical-22 points·2 months ago

a template letter that quotes their own criteria back is the strongest one

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u/adaeze_weiss20 points·2 months ago

Employer plan or individual plan?

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The paperwork war. Prior-authorisation criteria, denial reason codes, step-therapy documentation, external review, employer carve-outs, and the appeal letter templates the community has iterated on for three years. Mostly US-shaped but the tactics generalise.

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