c/insurancefights wiki

What this community is for

The paperwork war. Prior-authorisation criteria, denial reason codes, step-therapy documentation, external review, employer carve-outs, and the appeal letter templates the community has iterated on for three years. Mostly US-shaped but the tactics generalise.

c/insurancefights was created on 1 Dec 2023 and currently has 46,100 members and 95 captured submissions. It sits in the second tier of the site, which mostly affects how fast a question gets answered rather than how well.

Rules, and why each exists

Community rules come first, then the six site-wide rules that apply everywhere on GLP Research Hub. Community rules are enforced by the moderators listed at the bottom of this page; site rules are enforced by everyone.

1. Say which country and which plan type. "Insurance" means eleven different things.
2. Redact member ids and group numbers from every screenshot.
3. Do not suggest misrepresenting a diagnosis. That is fraud and it gets you banned.

And the site rules, which are short on purpose:

1. Independent community. Nobody here sells anything, and anyone who tries is banned.
2. Not medical advice. Describe what you did; never prescribe to a stranger.
3. Claims need evidence. Batch numbers, dated screenshots, independent test reports, or a citation.
4. No referral links, discount codes or affiliate URLs. Permanent ban, no appeal.
5. No contact handles, wallet addresses or tracking numbers — they identify people.
6. Be recognisably decent. Disagree hard, insult nobody.

Terms you will see

Vocabulary that turns up constantly in c/insurancefights. Each links to the topic page, which collects every submission that touches it.

• prior authorization — an insurer requiring approval before it will pay.
• appeal — a formal challenge to a denial; usually fixable paperwork rather than policy.
• denial — a refusal to cover, carrying a reason code that tells you what to fix.
• formulary — the list of what a plan covers. Read the exclusions before the marketing.
• step therapy — having to fail something cheaper first, with the failure documented.
• external review — independent review after internal appeals are exhausted.
• copay — discussed frequently in this community — see the topic page for every submission that touches it.

Start here

The twelve highest-scoring submissions in this community. Not necessarily the most correct — the most agreed-with, which is a different thing, and worth remembering when you read them.

1. [Question] step therapy — what am I missing here — 5.6k points, 49 comments, 2 years ago
2. Spain: copay, and what it actually costs here — 5k points, 55 comments, 2 years ago
3. [Discussion] can we stop arguing about appeal until somebody posts a number — 4.1k points, 45 comments, 1 year ago
4. [Question] Spain — has anyone got a straight answer on denial — 3.9k points, 26 comments, 2 years ago
5. the step therapy question that gets asked weekly, answered properly — 3.9k points, 65 comments, 1 year ago
6. why does nobody talk about step therapy — 3.8k points, 15 comments, 1 year ago
7. Germany: external review, and what it actually costs here — 3.7k points, 38 comments, 1 year ago
8. someone explain external review to me like I have not read a paper in years — 3.2k points, 33 comments, 2 years ago
9. unpopular opinion: most of what gets said here about denial is guesswork — 3.2k points, 58 comments, 2 years ago
10. [Discussion] denial is doing more work than we give it credit for — 3.2k points, 62 comments, 1 year ago
11. how much of what we believe about step therapy actually comes from prior authorization threads — 3.1k points, 9 comments, 10 months ago
12. the copay thing finally clicked for me and I want to write it down — 3.1k points, 52 comments, 1 year ago

Asked constantly

• [Question] step therapy — how do i document failing something cheaper
• [Question] does the copay card stack with anything or is that a myth
• [Question] the UK — has anyone got a straight answer on formulary
• [Question] how do you actually verify external review
• [Question] how do you actually verify step therapy
• unpopular opinion: most of what gets said here about appeal is guesswork
• three years of step therapy threads, summarised so you do not have to read them
• [Question] how do you actually verify appeal
• help me understand appeal, I have read the wiki twice
• [Question] how do you actually verify copay

If your question is on that list, read the answers there first. If it is not, ask it — that is what the community is for, and "this has been asked" is only a helpful reply when it comes with a link.

Who runs this

Moderation here is done by volunteers who also post as normal members. They are not clinicians, not vendors, and not paid.

• u/prior_auth_pain — Four denials, three appeals, one external review, eventually approved. Templates in my posts.
• u/formulary_fighter — Read the formulary exclusion list before you read the marketing.
• u/appeal_letter_al — My appeal letter template has been copied 200+ times. Take it, it is free.
• u/step_therapy_s — Step therapy means failing something cheaper first. Document the failure properly.