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c/insurancefights·submitted 2 years ago by u/karim_restrepo

[Meta] the appeal rule is doing its job and people should stop complaining

Appealbranch of 6 comments

Right, the denial question again, but with numbers this time. I have 5 data points over 16 weeks. The pattern is consistent enough that I do not think it is chance, and boring enough that nobody is going to screenshot it, which is usually a good sign. The thing I would flag for anyone new: the effect I am describing…

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6 comments, started 2 years ago
u/ilias_cabrera0 points·2 years ago

Australia plan: step therapy required 18 medications first. Did them all, got approval. The order matters.

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u/whois_wanda1 point·2 years ago

appeal letter templates are in the wiki

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u/karim_restrepoOP1 point·2 years ago

the UK plan: step therapy required 17 medications first. Did them all, got approval. The order matters.

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u/amira_dumitru1 point·2 years ago

formulary exclusions are negotiable sometimes

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u/karim_restrepoOP1 point·2 years ago

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

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u/RetaAndRegret21 point·2 years ago·edited

Strongly agree. Step therapy is predictable if you have the criteria.

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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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