Germany: external review, and what it actually costs here
Germany: external review, and what it actually costs here — a position I have arrived at slowly and would like tested.
Employer-sponsored plans may be regulated differently from individually purchased ones, which changes both the appeal route and which regulator hears a complaint.
Asked for the policy bulletin by number and wrote the appeal against its criteria line by line. Approved on the second level after a flat first-level denial.
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.
Ask me anything specific. Anything general I will probably get wrong.
best — the order this archive was captured in
A peer-to-peer conversation puts the prescribing clinician in front of a reviewing clinician. It bypasses the correspondence cycle entirely and is often the fastest available route.
Yes. Written, always, even when they tell you a phone call is sufficient.
Yes.
Adding the underused one — external review. Independent, binding where it applies, and hardly anybody gets that far.
the formulary is published, read it before you appeal
Added a jurisdiction tag — the answers differ completely between countries and plan types.
Careful — the deadline runs from the date on the letter. Waiting for a call back can cost you the appeal entirely.
Missed a deadline because I counted from when I opened the envelope. That mistake cost me an entire cycle.
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.