why does nobody talk about denial
Question in the title, detail here: why does nobody talk about denial. New plan year, entirely new criteria, and the denial that had been immovable in the autumn simply did not apply in January. The process that has actually worked for people on this board, in order. Get the denial in writing and find the criterion…
Right, and keeping every date and reference number turns a frustrating process into an auditable one.
That advice is jurisdiction-specific and this board spans several. Say where you are.
a template letter that quotes their own criteria back is the strongest one
Same view. The second-level appeal is where mine turned, after a first-level denial that looked final.
external review exists and almost nobody uses it
Missed a deadline because I counted from when I opened the envelope. That mistake cost me an entire cycle.
deadlines run from the letter date, not from when you opened it
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.
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.