[Win] approved after i sent them their own policy criteria back
The title is the argument: approved after i sent them their own policy criteria back. Here is the rest of it. 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.…
Peer-to-peer took fifteen minutes and resolved something a written appeal had been sitting on for a month.
ask for the denial reason in writing, always
ask for the denial reason in writing, always
This is the whole method. Answer the criterion they named, not the decision in general.
This is the whole method.
Agreed — and request the bulletin by number. They have to give it to you.
This is the whole method.
Adding the underused one — external review. Independent, binding where it applies, and hardly anybody gets that far.
Has a peer-to-peer been offered or requested?
Documented eighteen months of what had been tried in a one-page table. That table was the appeal.
Spent six weeks arguing in general terms and got nowhere. Two paragraphs quoting their own criteria turned it around in eleven days.