Topic summary

Prior authorisation: what the criteria usually require

Access › Insurance & coverage prior authorisation formulary appeals insurance Solved

This is a generated summary. It shows the 5 most-liked posts from a topic of 14, in their original order, with the accepted answer included where one exists. It is a reading aid and it will miss nuance — the full topic is the record.

t.verhoevenTL225 Jan 2025#1

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.

14 likes 18mo

f.weissTL2 Solution31 Jan 2025#2

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

Distinguishing three things in the prior authorisation discussion that keep getting used interchangeably: the observation, the proposed mechanism, and the recommendation that gets attached to both.

18 likes 18mo

c.okaforTL3Regular11 Feb 2025#5

dr_seong, post #3: 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. Go to post

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.

12 likes in reply to #3 18mo

k.asanteTL214 Feb 2025 · edited#6

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.

25 likes 17mo

sa.rasmussenTL29 Mar 2025#14

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.

22 likes 17mo

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An appeal that succeeded, with the letter structure — the long versionAccess › Insurance & coverage · 136 replies

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