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…
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 diagnosis code on the claim is doing more work than anything you write
That criterion is from the previous plan year. The current bulletin has different wording.
That criterion is from the previous plan year.
hassan_chowdhury is right that this is documentation rather than persuasion. It took me a year to accept that.
prior authorisation criteria change every plan year
ask for the denial reason in writing, always
Missed a deadline because I counted from when I opened the envelope. That mistake cost me an entire cycle.
prior authorisation criteria change every plan year
Agreed — and request the bulletin by number. They have to give it to you.
Documented eighteen months of what had been tried in a one-page table. That table was the appeal.
Step therapy requires documented trial of preferred alternatives.
Disagreeing with this line: the deadline runs from the letter date and treating it otherwise is expensive.
appeal in writing even when they say a call is enough