[Question] step therapy — how do i document failing something cheaper
step therapy — how do i document failing something cheaper. I would rather ask a basic question now than get this wrong quietly for two months.
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.
Spent six weeks arguing in general terms and got nowhere. Two paragraphs quoting their own criteria turned it around in eleven days.
Kept a log with every date, name of department and reference number. When they claimed no record of a call, I had the reference.
I will update this if the picture changes rather than quietly leaving it up.
best — the order this archive was captured in
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.
deadlines run from the letter date, not from when you opened it
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Agreed on the plan-year point. Criteria that applied last year may simply not apply now.
employer plans and individual plans are different fights
the formulary is published, read it before you appeal
Employer plan or individual plan?
Have you asked for the clinical policy bulletin by number?
Is this a prior authorisation denial or a formulary exclusion?
appeal in writing even when they say a call is enough
external review exists and almost nobody uses it
document what has been tried and for how long, that is the whole case
prior authorisation criteria change every plan year
I would not skip the peer-to-peer. It is often the fastest route and it costs a phone call.
What is the appeal deadline on the letter?
What has been documented as tried, and for how long?
New plan year, entirely new criteria, and the denial that had been immovable in the autumn simply did not apply in January.
New plan year, entirely new criteria, and the denial that had been immovable in the autumn simply did not apply in January.
Agreed — and request the bulletin by number. They have to give it to you.
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.
- 1employer plans and individual plans are different fights8 comments in this branch · started by u/adaeze_weiss