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c/insurancefights·submitted 5 months ago by u/vito_beaulieu

the step therapy question that gets asked weekly, answered properly

Questionbranch of 5 comments

Genuinely asking, not being difficult. Everyone in c/labresults repeats that appeal is important. I believe it, but I have never seen anyone show why, and when I search I get 16 threads of people agreeing with each other. Is there a paper? Is there a measurement? Or is this one of those things that is true because it…

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5 comments, started 5 months ago
u/controversial_only26 points·5 months ago

do not suggest misrepresenting a diagnosis, that is fraud

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u/vito_beaulieuOP18 points·4 months ago

Disagree but this is the good kind of wrong — it is specific enough to be checked.

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u/controversial_only11 points·4 months ago

copay is separate from coverage

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u/vito_beaulieuOP8 points·4 months ago

Copay was prior authorization for the copay then another 23% of the total. Read the actual plan document.

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u/formulary_fighterappeals10 points·4 months ago

prior auth criteria are state-specific, formulary differs

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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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  1. Say which country and which plan type. "Insurance" means eleven different things.
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