[Discussion] denial reason codes decoded, mostly fixable paperwork
denial reason codes decoded, mostly fixable paperwork. Making the case below, and I expect to lose some of it in the comments. Documented eighteen months of what had been tried in a one-page table. That table was the appeal. External review was the thing that finally worked. I did not know it existed until a thread…
Member and policy numbers redacted from the screenshot above. Everything else left as posted.
That criterion is from the previous plan year. The current bulletin has different wording.
Correcting myself upthread: the deadline was 5 days, not the figure I gave.
Same view. The second-level appeal is where mine turned, after a first-level denial that looked final.
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Agreed on the plan-year point. Criteria that applied last year may simply not apply now.
step therapy is a documentation problem, not an argument
keep every date, every reference number, every name of a department
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.
Yes. Written, always, even when they tell you a phone call is sufficient.