If an insurance provider denied a claim that is crucial to your health, consider filing an internal appeal. Check your plan documents or website for information regarding this process and deadlines.
Proving medical necessity is usually the easiest way to overturn a denial. You may need to go through two-tier appeals process with external review.
1. Be Persistent
Your health insurance company is within their right to deny a service, treatment or medication and you have every right to appeal this decision. More than half of appeals for coverage or reimbursement are approved so it’s vitally important that when filing an appeal you remain persistent in doing so.
Resolving an insurance denial can be a challenging and cumbersome process, which is why keeping records of all communication with your provider can be extremely important in following all the appropriate channels for filing an appeal and adhering to its guidelines. An ideal method for this would be using either a spreadsheet or form for tracking the entirety of your appeal process as well as documents sent over.
Health care attorney Domna Antoniadis, co-director of Access to Care nonprofit, advises people with commercial insurance plans to read their plan documents. She suggests finding and reviewing the section detailing how to file an appeal before reaching out to your insurer regarding a denied claim. In some plans there may also be a window of time in which appeals can be filed.
Request a copy of your insurance company’s decision on your claim as soon as you can; this will provide more insight into their reasoning, making it easier to argue why your appeal should be approved. If they deny your appeal, try asking if there is someone available who can assist with filing external reviews instead.
If all internal appeals have failed and you still cannot obtain medically necessary treatments, contact your state Department of Insurance to see what options exist for consumer assistance programs that could provide assistance. In addition, check your policy’s documents to see if there is information about a patient advocate program.
2. Be Specific
No matter if it is an insurance company’s decision to deny your claim or superbill for out-of-network reimbursement, when appealing it you should provide specific reasons why your request should be granted. Denials often result from miscommunication or minor errors and your chances of success increase by clearly explaining where such errors occurred.
Understanding your insurer’s appeals process and timeline is also vitally important, which should be readily available on both their card and website. From there you can assess if internal appeal will suffice or whether an external review should take place.
Once you have all of the required information, it’s time to craft your letter of appeal. Your appeal should be polite yet detailed enough for an insurance company representative to understand all aspects of your case. Write directly to both parties involved: address it to both an insurer and person who denied your claim while explaining why and providing any supporting documentation as proof.
Make sure to include all relevant details about your case, such as contact info, documents submitted and insurance coverage information. Also include the date and reason of the initial denial and appeal; this will enable the insurance company to locate it more easily. Submit everything on time; missing a deadline may disqualify your case. Moreover, include evidence supporting medical necessity of requested treatments (i.e. letters from health care providers or research studies that demonstrate its efficacy for your particular condition).
3. Be Organized
Your health insurance provider must inform you why a claim was denied or coverage terminated, as well as provide you with a process for appealing the decision. When appealing a decision, take careful notes during all phone calls and record any relevant next steps or other details relevant to this appeals process. In addition, store all copies, records, and documents in one location until all processes have been finalized.
After compiling all the information needed, it’s time to draft an effective letter of appeal. Address it directly to those responsible and begin by summarizing what occurred – include any supporting documentation and plan language as applicable – while being polite and professional throughout.
4. Be Polite
Be courteous when appealing a decision of an insurance company; even when upset and frustrated about its decision. Retain your emotions so you can clearly and effectively convey why the claim should be covered; have someone review the letter beforehand if possible to make sure its tone remains professional and respectful.
Your letter should begin by explaining that you are appealing the decision of an insurance company to deny coverage for medical services or medication you request, then reference their written notice of rejection to explain why this decision has been made. Doing this demonstrates your awareness of their reasoning while setting up your counterarguments.
As part of your letter, state why a specific treatment or medication is medically necessary in your situation. Cite any relevant literature, plan benefits or specific information from healthcare providers which supports your request. Depending on the nature of your claim, you may also wish to include copies of any supporting documentation such as medical records, diagnostic tests or bills as proof.
At the conclusion of your letter, thank the insurance company for considering your appeal and for taking their time in reviewing it. Sign your letter preferably by hand (though scanned signatures can also be acceptable), to show that you value their effort to review your case. Adding personal touches such as writing “Please consider my appeal”, will show them you care and want a swift resolution to it all.
5. Be Honest
If you are appealing an insurance claim denial, be honest in your communications with them. Review their documentation that supports their decision so that it will reflect accurately in your arguments – don’t fudge the facts just so your argument appears more persuasive!
If the insurance company rejects your appeal, you may need to seek an external review by an impartial third party. While this process will likely take more time than internal appeals, you could possibly receive a final determination within four months. Be patient while keeping track of all communication with them such as names of individuals you speak to and dates/topics discussed/agreed upon.
Insurance companies take appeals seriously and have entire departments dedicated to reviewing claims and appealing them. Without experience in law or an in-depth knowledge of your health insurance policy, it would not be wise for an individual to attempt an appeal on their own. ERISA appeals are different than ordinary appeals in that you cannot build a case at trial like you can with other forms of lawsuits.
There is good news: over half of denials for coverage or reimbursement can ultimately be overturned through appeal. But this process can be daunting and difficult to manage on your own; therefore, having someone there to guide and assist can be invaluable.
