[Discussion] denial reason codes decoded, mostly fixable paperwork
denial reason codes decoded, mostly fixable paperwork. Making the case below, and I expect to lose some of it in the comments. Documented eighteen months of what had been tried in a one-page table. That table was the appeal. External review was the thing that finally worked. I did not know it existed until a thread…
A denial letter is required to state a reason and to reference the criterion applied. That reference is the handle: request the clinical policy document by its identifier and answer it point by point.
external review exists and almost nobody uses it
Push back: your plan is an employer plan, which changes both the appeal path and who the regulator is.
Small fix — external review is independent of the plan. The second-level internal appeal is not.
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
prior authorisation criteria change every plan year
Is this a prior authorisation denial or a formulary exclusion?