Appeals - preparing your appeal

Preparing your appeal

You've tried to use your insurance to cover some treatment or service, and have been denied. You want to appeal the denial and request that the insurer cover the service. Remember that the Office of the Healthcare Advocate can assist with this process, or even or advocate directly with the insurer on your behalf. However, if you prefer to draft your own appeal, these are some suggestions how to do so in a manner that most effectively presents your case and addresses the elements that the insurer will need answers to.

Step One:

Ensure that you know what specifically has been denied, and why. Sometimes, a service might include multiple services that are processed and paid individually, and the insurer may only deny a portion of those services. To understand this, you should carefully read the letter you received from the insurer denying the service.

There are many reasons that a service may be denied.

1. The service may not be a covered benefit under your plan. For more information about understanding your plan, click here.

2. Your plan may require pre-authorization for the service, and your provider may not have requested this before you received the service.

3. There may be errors or missing information in your claim. This could be as simple as getting your birthday wrong, or a typo in your insurance number. The insurer may also request medical records that support the need, or medical necessity, for the service, and the provider may not have provided the records.

For some examples of insurance denials, click here.

Call Your Health Plan

Many problems and concerns may be resolved by your insurer's customer service (also called "member services"). You can find the toll-free number to contact them on your membership card.

The health plan has an obligation to help you resolve your problems. Be sure to ask for and write down the time and date of the call, as well as the name of the person assisting you so you have a record of your efforts and the information you received.

You may ask for any information they used to make their decision to deny the service, including your full plan document, any clinical policy they applied to your request, clinical peer-reviewed resources supporting their policy, and any internal notes about the review of your request, such as a peer-reviewer's evaluation of the claim.

Talk to Your Provider

If the insurer denied the service, ask your provider or their staff what information was submitted to the plan and ask for a copy of the information and the letter written by your doctor to the plan requesting payment authorization.

If the insurer denied the requested service because it feels an alternate treatment is more appropriate and consistent with the standard of care for your condition, ask your provider about it. Are there other options beyond what's been requested?

If there are, it doesn't mean that these alternatives are right for you - that's a discussion you and your provider should have. It also doesn't mean that the service you've requested, or already received, wasn't the best treatment for you and that it shouldn't be covered by your insurance. It simply means that the insurer has a different perspective about what would be the standard of care.

Call Your Employer

If you get your health coverage through your own or your spouse's job, the human resources or benefits manager may be able to help resolve any questions about benefits and health plan policies. If you received an employee handbook, check it to see if there is a procedure to follow regarding questions or problems with your health benefits.

Now that you have talked to all parties involved, doctor, health plan, and employer, you should have a good understanding of what went wrong. If you are not satisfied with the resolution of your problem at this point, you can file a formal appeal. You will probably need to submit your description of the problem in writing. Step Two will go into more detail about filing a formal appeal or complaint.

Preparing Your Appeal - Step Two