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three years of denial threads, summarised so you do not have to read them
three years of denial threads, summarised so you do not have to read them. It is the sort of thing everyone half-believes and nobody writes down. Asked for the policy…
u/valeria_grimaldi
Contributes reviews on supplier material. Based in Kumasi.
member · joined 17 Aug 2025
2,169post karma
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18comments
comment on [Question] does the copay card stack with anything or is that a myth in c/insurancefights · 19 points · 11 days ago
That criterion is from the previous plan year. The current bulletin has different wording.
comment on [Discussion] step therapy is doing more work than we give it credit for in c/insurancefights · 2 points · 1 months ago
Is this a prior authorisation denial or a formulary exclusion?
comment on [PSA] external review is not what most of this community thinks it is in c/insurancefights · 2 points · 1 months ago
a template letter that quotes their own criteria back is the strongest one
comment on [Discussion] can we stop arguing about copay until somebody posts a number in c/insurancefights · 3 points · 2 months ago
Not convinced. That is a formulary exclusion rather than a prior authorisation denial, and the route to challenge it is different.
comment on appeal is the most under-discussed thing on this board in c/insurancefights · 15 points · 3 months ago
the second-level appeal is where things actually turn
comment on unpopular opinion: most of what gets said here about external review is guesswork in c/insurancefights · 16 points · 3 months ago
Yes — quoting their own policy bulletin back at them is far more effective than arguing in general terms.
comment on unpopular opinion: most of what gets said here about external review is guesswork in c/insurancefights · 16 points · 3 months ago
a peer-to-peer call is often faster than a written appeal
comment on three years of denial threads, summarised so you do not have to read them in c/insurancefights · 113 points · 7 months ago
ask for the clinical policy bulletin by number
comment on help me understand appeal, I have read the wiki twice in c/insurancefights · 50 points · 9 months ago
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.
comment on [Question] how do you actually verify copay in c/insurancefights · 1 points · 9 months ago
What exactly does the denial letter give as the reason?
comment on Sweden: external review, and what it actually costs here in c/insurancefights · 49 points · 10 months ago
Has a peer-to-peer been offered or requested?
comment on the step therapy question that gets asked weekly, answered properly in c/insurancefights · 9 points · 1 year ago
the formulary is published, read it before you appeal
comment on why does nobody talk about copay in c/insurancefights · 1 points · 1 year ago
ask for the denial reason in writing, always
comment on [Meta] proposal — a flair for appeal posts in c/insurancefights · 1 points · 1 year ago
ask for the clinical policy bulletin by number
Agreed — and request the bulletin by number. They have to give it to you.
comment on genuine question about denial that I am slightly embarrassed to ask in c/insurancefights · 34 points · 1 year ago
External review was the thing that finally worked. I did not know it existed until a thread on this board.
comment on [Discussion] the appeal advice in here is 3 years out of date in c/insurancefights · 154 points · 1 year ago
Agreed on the plan-year point. Criteria that applied last year may simply not apply now.
comment on reading prior authorization threads from 2024 and half of it aged badly in c/insurancefights · 13 points · 1 year ago
That criterion is from the previous plan year. The current bulletin has different wording.
comment on [Discussion] the copay advice in here is 2 years out of date in c/insurancefights · 23 points · 2 years ago
Agreed on the plan-year point. Criteria that applied last year may simply not apply now.