genuine question about denial that I am slightly embarrassed to ask
The title is the whole question — genuine question about denial that I am slightly embarrassed to ask — but here is why I am asking. Prior authorisation criteria are republished each plan year. A criterion that blocked you in one year may not exist in the next, so a denial is worth retesting after the turnover. A…
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.
New plan year, entirely new criteria, and the denial that had been immovable in the autumn simply did not apply in January.
Asked for the policy bulletin by number and wrote the appeal against its criteria line by line. Approved on the second level after a flat first-level denial.
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
a template letter that quotes their own criteria back is the strongest one
Has a peer-to-peer been offered or requested?
the second-level appeal is where things actually turn