[Denied] employer carve-out was in the plan document, not the summary
employer carve-out was in the plan document, not the summary. I have gone back and forth on this for months.
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.
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.
I will update this if the picture changes rather than quietly leaving it up.
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.
A peer-to-peer conversation puts the prescribing clinician in front of a reviewing clinician.
Agreed — and request the bulletin by number. They have to give it to you.
Disagree with the tone strategy. Anger has never moved a determination; matching the criterion has.
What has been documented as tried, and for how long?
Yes — quoting their own policy bulletin back at them is far more effective than arguing in general terms.
I would not skip the peer-to-peer. It is often the fastest route and it costs a phone call.
the diagnosis code on the claim is doing more work than anything you write
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.
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.
a peer-to-peer call is often faster than a written appeal
Left up. It carries dates, a criterion and an outcome, which is what makes these threads useful.
Careful — the deadline runs from the date on the letter. Waiting for a call back can cost you the appeal entirely.
prior authorisation criteria change every plan year
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.
keep every date, every reference number, every name of a department
step therapy is a documentation problem, not an argument
Employer-sponsored plans may be regulated differently from individually purchased ones, which changes both the appeal route and which regulator hears a complaint.
Right, and keeping every date and reference number turns a frustrating process into an auditable one.
ask for the denial reason in writing, always