[Discussion] the appeal advice in here is 2 years out of date
the appeal advice in here is 2 years out of date, which sounds obvious until you try to state the evidence for it. Pulling the figures out of the title: 2 years. All of it is written down as it happened rather than reconstructed. Internal appeals are decided by the plan. External review is decided by an independent…
I would not skip the peer-to-peer. It is often the fastest route and it costs a phone call.
This. Step therapy is a paperwork requirement and it is beaten with documentation, not persuasion.
Kept a log with every date, name of department and reference number. When they claimed no record of a call, I had the reference.
Yes — quoting their own policy bulletin back at them is far more effective than arguing in general terms.
deadlines run from the letter date, not from when you opened it
the second-level appeal is where things actually turn
Which country and which plan year are we talking about?
the formulary is published, read it before you appeal
Is this a prior authorisation denial or a formulary exclusion?
That criterion is from the previous plan year. The current bulletin has different wording.