why does nobody talk about formulary
why does nobody talk about formulary — that is what I am asking, and I have already read the wiki twice. 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…
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.
the formulary is published, read it before you appeal
Internal appeals are decided by the plan.
vikram_mbeki is right that this is documentation rather than persuasion. It took me a year to accept that.
Which country and which plan year are we talking about?
Small fix — external review is independent of the plan. The second-level internal appeal is not.
Kept a log with every date, name of department and reference number. When they claimed no record of a call, I had the reference.
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.
deadlines run from the letter date, not from when you opened it
Appeal deadlines run from the date on the determination letter.
Disagreeing with this line: the deadline runs from the letter date and treating it otherwise is expensive.
employer plans and individual plans are different fights
the denial letter names the criterion, start there