[Discussion] can we stop arguing about appeal until somebody posts a number
can we stop arguing about appeal until somebody posts a number — that is what I am asking, and I have already read the wiki twice.
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.
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.
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.
If two or three other people have done the same thing we might actually learn something. Alone it is an anecdote.
best — the order this archive was captured in
A peer-to-peer conversation puts the prescribing clinician in front of a reviewing clinician. It bypasses the correspondence cycle entirely and is often the fastest available route.
New plan year, entirely new criteria, and the denial that had been immovable in the autumn simply did not apply in January.
What is the appeal deadline on the letter?
Left up. It carries dates, a criterion and an outcome, which is what makes these threads useful.
What has been documented as tried, and for how long?
a peer-to-peer call is often faster than a written appeal
Spent six weeks arguing in general terms and got nowhere. Two paragraphs quoting their own criteria turned it around in eleven days.
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
I would not skip the peer-to-peer. It is often the fastest route and it costs a phone call.
This. Step therapy is a paperwork requirement and it is beaten with documentation, not persuasion.
Kept a log with every date, name of department and reference number. When they claimed no record of a call, I had the reference.
Employer-sponsored plans may be regulated differently from individually purchased ones, which changes both the appeal route and which regulator hears a complaint.
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.
Missed a deadline because I counted from when I opened the envelope. That mistake cost me an entire cycle.
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.
Documented eighteen months of what had been tried in a one-page table. That table was the appeal.
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.
Appeal deadlines run from the date on the determination letter. They are strict, they are short, and a missed deadline usually forfeits that level entirely.
Prior authorisation criteria are republished each plan year.
Disagreeing with this line: the deadline runs from the letter date and treating it otherwise is expensive.
the formulary is published, read it before you appeal
Right, and keeping every date and reference number turns a frustrating process into an auditable one.
Disagreeing with this line: the deadline runs from the letter date and treating it otherwise is expensive.
Adding the underused one — external review. Independent, binding where it applies, and hardly anybody gets that far.
employer plans and individual plans are different fights
Is this a prior authorisation denial or a formulary exclusion?
External review was the thing that finally worked. I did not know it existed until a thread on this board.
prior authorisation criteria change every plan year
prior authorisation criteria change every plan year
Agreed — and request the bulletin by number. They have to give it to you.
prior authorisation criteria change every plan year
canada_coverage is right that this is documentation rather than persuasion. It took me a year to accept that.
That criterion is from the previous plan year. The current bulletin has different wording.
- 1A peer-to-peer conversation puts the prescribing clinician in front of a…7 comments in this branch · started by u/hplc_hobbyist
- 2employer plans and individual plans are different fights7 comments in this branch · started by u/runa_wikstrom