Prior authorisation: what the criteria usually require

On the subject in the title: Prior authorisation: what the criteria usually require Working notes rather than a conclusion.

I would like to know what people here actually do about prior authorisation, as distinct from what is usually recommended. Those have diverged in every other subject I have looked at closely.

Mine is below, with the reasoning, including the parts I am not confident about.

Where an exception process exists separately from an appeal, they are different routes with different criteria and using the wrong one loses time.

The literature is thinner on this than the confidence in the thread implies.

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

I would rather be precise about what I do not know than vague about what I do.

An honest declaration on prior authorisation: I have a prior here and it is strong enough that you should weight what I say downward. Stating it rather than hiding it.

A clinician's supporting letter that addresses the criteria explicitly is worth considerably more than one that describes the patient generally.

Worth one more sentence than it usually gets.

Taking post #6 at face value and following it one step further.

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.

Second this, and I would have said it less carefully.

Adding the measurement that post #6 says would settle it.

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

The single most useful preparation is obtaining the actual criteria document rather than working from what somebody was told on the phone.

Two people can read the same figure differently here and both be reasonable.

Helpful, and easy to find again, which is half of what a good reply is.

Tier placement and step therapy: some formularies place a medication on a higher tier or require you to fail cheaper alternatives before approving the one you want. Understanding the requirements before treatment starts matters.

The arithmetic on prior authorisation is the easy part and it is where the errors are, which is an uncomfortable combination. Show your working and someone will catch it.

Picking up post #12: that is the part I would want checked first.

What does not work: describing how the decision made you feel, however justified. The reviewer is checking criteria and the job is to make them checkable.

The reasoning is more useful than the number, which is why I have shown it.