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by Neil Bartlett




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Having a medical claim denied hurts—it adds to the pain you and your loved ones are experiencing.

Remember: You have rights and power. An in-depth study of data from four states by Kaiser Family Foundation in 2002 showed that 52% of patients won their first appeal.

These steps may help you win an appeal when you’ve been denied coverage for a medical claim.

Understand illness, insurance

Before you discuss the case with the insurance company or carrier, understand your or your loved one’s condition. Obtain and read copies of any letters your doctor may have submitted to the insurance company.

Make sure the denial letter complies with federal regulations.

Also, know your insurance. If coverage is through your employer or through your spouse’s or partner’s employer, call your benefits manager and ask for an explanation of the coverage.

Find out what is required to appeal a denial of a medical claim under your plan. Health plans often have different appeals processes for different types of disputes. A plan may have a different process for resolving a complaint about appointment times, than for an appeal involving a denial of a benefit or a refusal to authorize a medical procedure. Federal ERISA (Employee Retirement Income Security Act) regulations set up other requirements for employer-sponsored health plan appeals.

Gather preliminary information

Gather information so you can write a letter to appeal the decision.

  • Start a notebook. Keep a record of all letters you receive and a log of all telephone calls you make or receive related to the denial. Note the name of the person and the date.
  • Keep track of details. Record when and how you received notice of the denial. Did your doctor notify you directly, or did the administrator or insurer notify you directly?
  • Watch for nonpayment notices. Did you receive a statement from your insurance company stating that your bills will not be paid?
  • Talk with your doctor. He or she may have other pertinent information to include in your appeal letter.
  • Make sure the denial letter complies with federal regulations. Under ERISA, your denial letter should include the reason for the denial, as well as a specific reference to pertinent plan provisions on which the denial is based.
  • Obtain a current copy of your health-care plan document and plan summary, or health insurance booklets.

If your appeal is denied, press on.Finally, know whom you can contact to discuss the denial. The denial letter may contain this information.

Write an appeal letter

An appeal letter should include your policy and group numbers, claim number, and other information to identify your case. Note the reason for the denial, a brief history of the illness and necessary treatment, the correct information about your case, why you believe the decision was wrong, and what you’re asking the insurance company to do. Include:

  • A letter from your doctor and specialist addressing specifics of your case.
  • Any pertinent information from your medical records.
  • Any articles from peer-reviewed clinical journals that support your case.

Keep the letter professional. Keep frustration and anger out.

Evaluate the result

You might receive a phone call or letter telling you that your denial has been overturned and that the insurance company will cover the procedure. If so, way to go. Be sure to request a copy of the approval letter, and make sure you’re aware of any conditions included.

Health plans often have different appeals processes for different types of disputes.If your appeal is denied, you also need a copy of the letter. Read it carefully—it may have a different reason for the denial. Notify your doctor of the decision and any new information requested of you in the letter.

Despite a denial, press on. Request an independent evaluation, contact the state insurance commissioner, or contact patient advocacy groups. The Kaiser study mentioned earlier found that people who appealed a second time won 44% of the time.

It may be necessary to consult an attorney. You have to decide whether it's worth the money and effort. If you exhaust your appeals, some advocacy groups may offer assistance in paying bills, and some treatment centers may offer reduced-rate or sliding scale treatments.

Resources

Links:
Patient Advocate Foundation

State Insurance department Web sites

Kaiser Family Foundation—A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan (2005 Update)


 

Published June 24, 2013

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