[Discussion] formulary is doing more work than we give it credit for
formulary is doing more work than we give it credit for. Change my mind, genuinely — I have no stake in being right about this. 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.…
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.
prior authorisation criteria change every plan year
the denial letter names the criterion, start there
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.
Careful — the deadline runs from the date on the letter. Waiting for a call back can cost you the appeal entirely.
External review was the thing that finally worked. I did not know it existed until a thread on this board.
a template letter that quotes their own criteria back is the strongest one
Spent six weeks arguing in general terms and got nowhere. Two paragraphs quoting their own criteria turned it around in eleven days.
ask for the denial reason in writing, always