[Discussion] we are measuring external review at the wrong time and calling it noise
The title is the argument: we are measuring external review at the wrong time and calling it noise. Here is the rest of it.
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 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.
Employer-sponsored plans may be regulated differently from individually purchased ones, which changes both the appeal route and which regulator hears a complaint.
Screenshot none of this. Read the whole thread, including the parts where I am told I am wrong.
best — the order this archive was captured in
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.
Right, and keeping every date and reference number turns a frustrating process into an auditable one.
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the second-level appeal is where things actually turn
Yes — quoting their own policy bulletin back at them is far more effective than arguing in general terms.
external review exists and almost nobody uses it
I would not skip the peer-to-peer. It is often the fastest route and it costs a phone call.
That advice is jurisdiction-specific and this board spans several. Say where you are.
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.
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
deadlines run from the letter date, not from when you opened it
employer plans and individual plans are different fights
Yes. Written, always, even when they tell you a phone call is sufficient.
step therapy is a documentation problem, not an argument
Kept a log with every date, name of department and reference number. When they claimed no record of a call, I had the reference.
Which country and which plan year are we talking about?
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.
step therapy is a documentation problem, not an argument
saskia_rahimi is right that this is documentation rather than persuasion. It took me a year to accept that.
What has been documented as tried, and for how long?
prior authorisation criteria change every plan year
a template letter that quotes their own criteria back is the strongest one
the formulary is published, read it before you appeal
What is the appeal deadline on the letter?
- 1Right, and keeping every date and reference number turns a frustrating…12 comments in this branch · started by u/marta_marchand
- 2step therapy is a documentation problem, not an argument10 comments in this branch · started by u/saskia_rahimi