why does nobody talk about prior authorization
why does nobody talk about prior authorization. Searched first, found three threads that contradict each other, hence the post. External review was the thing that finally worked. I did not know it existed until a thread on this board. Missed a deadline because I counted from when I opened the envelope. That mistake…
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.
What is the appeal deadline on the letter?
Agreed on the plan-year point. Criteria that applied last year may simply not apply now.
Yes — quoting their own policy bulletin back at them is far more effective than arguing in general terms.
This. Step therapy is a paperwork requirement and it is beaten with documentation, not persuasion.
Yes. Written, always, even when they tell you a phone call is sufficient.
ask for the denial reason in writing, always
Have you asked for the clinical policy bulletin by number?
the denial letter names the criterion, start there
Employer-sponsored plans may be regulated differently from individually purchased ones, which changes both the appeal route and which regulator hears a complaint.