Have you ever filed an appeal because a prior authorization (PA) was denied? Of course, you have. We receive an average of 60 appeals requests per month. Many of these appeal requests, especially the ones for prescription drugs, don’t require an appeal for a favorable outcome. In fact, at least half of all prescription drug PAs that are denied for not meeting medical criteria were subsequently approved once we received additional necessary information. 

Your options before filing an appeal

Requesting an appeal as an immediate response to a denial limits the review opportunities for you and your patient.

Once an appeal is filed, the formal appeals process must be followed, which can be unnecessarily time consuming, especially for someone who needs a service or a medication quickly.  If the service or medication is denied on appeal, and the member would like to dispute that decision, their only recourse would be to go through an independent external review.

Additionally, choosing to initiate an appeal as a first attempt immediately following a denial, bypasses two opportunities that can result in a timelier favorable outcome for your patient.

Option #1: Re-review

Instead of requesting an appeal after an initial denial, simply ask for help from AllWays Health Partners customer service or, in the case of a prescription denial, CVS customer service. We can help identify the reason for the denial, including what key information may be missing. In many cases, you simply need to provide additional information to have your PA approved without an appeal.  

Option #2: Reconsideration

To initiate this option, simply contact us to request the reconsideration. You can speed up the reconsideration by including additional relevant information with your request. Reconsideration is less formal and less time consuming than an appeal. There is also an opportunity in this step for a peer to peer discussion between your requesting provider and an appropriate clinician to determine medical necessity coverage. You can learn more about reconsideration the initial denial letter sent by AllWays Health Partners or CVS.

3 tips to avoid denial

The best outcome for you and your patients is a PA that’s approved on first submission – no need for reconsideration or appeal. Here are 3 tips to help you get your PAs approved quickly:

  • Include as much detail and relevant clinical documentation as possible
  • Submit the request before you provide a service
  • Check a member’s eligibility and benefits before you request a PA
  • Check the authorizations page on our website to determine medical criteria for intended service, medication, or durable item.

 

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