[Discussion] we are measuring external review at the wrong time and calling it noise
The title is the argument: we are measuring external review at the wrong time and calling it noise. Here is the rest of it. 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. A peer-to-peer…
Right, and keeping every date and reference number turns a frustrating process into an auditable one.
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the second-level appeal is where things actually turn
Yes — quoting their own policy bulletin back at them is far more effective than arguing in general terms.
external review exists and almost nobody uses it
I would not skip the peer-to-peer. It is often the fastest route and it costs a phone call.
That advice is jurisdiction-specific and this board spans several. Say where you are.
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. Where it applies its decision binds the plan, and the deadlines to request it are short and strictly enforced.
The two things that trip people up: not knowing it exists, and exhausting the internal levels so slowly that the external window closes. Ask on the first denial what the external route is and what the deadline will be. Availability and rules vary by jurisdiction and plan type, so say where you are when you ask here.
Correction: that is a formulary exclusion, not a prior authorisation denial. Different form, different route, different deadline.
deadlines run from the letter date, not from when you opened it
employer plans and individual plans are different fights