Follow-up: Prior authorisation: what the criteria usually require posts 91–101

Since Prior authorisation keeps coming up, it should probably be a maintained page rather than a recurring thread. I am happy to draft it if someone with more direct experience will review it.

Quietly grateful for the plain phrasing. Not every thread gets that.

Where a criterion requires documented prior attempts, the documentation has to exist in the record rather than in your memory of it.

Worth one more sentence than it usually gets.

I had written a reply contradicting post #90 and deleted it. Here is what survived.

Formulary changes happen on a published schedule, so a denial now may be answering criteria that change shortly.

The interesting part of this is the exception, and I do not understand the exception.

I would call the community position on Prior authorisation likely rather than established, and I would be comfortable defending that hedge.

One more thing on Prior authorisation that took me far too long to see: the two figures people quote are not measuring the same quantity. Once you notice that, the apparent contradiction disappears.

Post #96 is right about the mechanism and I think understates the practical bit.

Prior authorisation: pre-approval requirements and how to satisfy them. Most denials cite specific criteria. Understanding the criterion is the first step in satisfying it.

Coming back to post #94, because the follow-up matters more than the original answer.

Prior authorisation is a question about a distribution, not about a value, and treating it as a value is what produces the confident wrong answers.

Narrowing post #96, because the general version has more than one answer.

Prior authorisation came up in a thread eighteen months ago and was answered well. I cannot find it, which is itself the problem, so here is the reconstruction.

Everything in post #98 holds. The case it does not cover is the one I have.

Date every account in this subcategory. Payer criteria change frequently and the archive keeps posts permanently.

A note on how Prior authorisation gets discussed rather than on Prior authorisation itself: the confident posts get the replies and the careful ones get ignored, and the careful ones have been right more often.