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c/insurancefights·submitted 10 days ago by u/controversial_only

[Win] approved after i sent them their own policy criteria back

Winbranch of 5 comments

Quick one. Canada here. appeal works very differently where I live than in the threads that dominate the front page, and I keep seeing people confidently given advice that simply does not apply outside the US. Specifics: the route I used took 21 weeks and cost roughly what I expected. The admin was worse than the…

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5 comments, started 9 days ago
u/amylin_amyamylin33 points·9 days ago

the carve-out clause varies by employer

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u/controversial_onlyOP15 points·9 days ago

Copay was step therapy for the copay then another 7% of the total. Read the actual plan document.

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u/prior_auth_painappeals18 points·9 days ago

External review overturned the denial. Took 22 weeks but the process exists.

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u/maren_ibarra10 points·8 days ago

formulary exclusions are negotiable sometimes

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u/sofia_nascimento8 points·8 days ago

resubmission after denial requires new documentation

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About c/insurancefights

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.

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