REAL-WORLD SKILL | CLASSROOM SIMULATION

Read the denial like your money depends on it.

NORTHSTAR EMPLOYEE HEALTH PLAN
ADVERSE BENEFIT DETERMINATION — CLASSROOM SIMULATION

Decision: Coverage for LUPRAVA 20 mg is denied because the plan's medical-necessity criteria were not met.

Plan basis: Medical Policy RX-214 requires documentation of two prior covered therapies or a prescriber's statement explaining why those therapies are contraindicated.

Your appeal right: You or your authorized representative may file an internal appeal within 180 days of receiving this notice.

What to send: this notice, the prescriber's medical-necessity statement, relevant treatment records, and any additional evidence you want considered.

Where: Appeals Unit, Northstar Employee Health Plan, PO Box 1180, Atlanta, GA 30301. Urgent appeals: 800-555-0147.

1. Why was coverage denied?2. What is the appeal deadline?3. What evidence could strengthen the appeal?4. Where and how is the appeal filed?

Nothing here is submitted or saved. The check runs on your own phone. This is a fictional job-based plan notice built for class. In real life, follow the deadline and instructions in the actual notice.