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You can ask that your insurance company reconsider its decision. Insurers have to tell you why they’ve denied your claim or ended your coverage. And they have to let you know how you can dispute their decisions.
Note: If you want to appeal a Marketplace decision about eligibility or tax credits, see Can I appeal a Marketplace decision?
There are two ways to appeal a health plan decision:
July 11, 2011 | The New York Times
It's unsettling to receive a letter from your insurance company telling you that your request for medical care, or for payment of care you've already received, has been denied. But there are some steps you can take to help boost the odds of filing a successful appeal.
Martin Rosen, a co-founder of Health Advocate, a business that helps people who get their insurance through their employer navigate dealings with their insurance company, says the key to avoiding a denial in the first place is knowing the details of your insurance policy before you seek treatment. (The company also offers advocacy services, for a fee, through Health Proponent, for those who buy insurance on their own.) But if you do receive a letter denying coverage, and you and your doctor believe you have a strong case to fight the denial, Mr. Rosen offers these tips:
- Check the details of your insurer's appeals process. In the coverage documents and summary of benefits, insurance companies are required to give all the tools needed to properly make an appeal. There are often deadlines to meet, so act quickly.
- Have your paperwork in order. Keep records of everything: the bills from your provider, your explanation of benefits, copies of denial letters, medical records, letters from your provider of care, etc.
- Call your human resources department if you receive coverage through your employer. The department may provide direction, advocate on your behalf and help to translate the fine print of the policy.
- Enlist the help of your doctor. Check the medical policy and ask your doctor to review it to prepare something called a letter of medical necessity to support your case.
- Take detailed notes when you speak to the insurance company. Write down the time and date, length of the call, the name and title of the person you speak with and all the details of the conversation. Make note of any follow-up activities and next steps by all parties.
- Write down your argument. Make notes of exactly what happened, when and why. If you are seeking approval for treatment, note any supporting science, clinical evidence, expected benefits, etc. Be clear, firm and concise. Make it clear that you plan to pursue the appeal until it is resolved, the claim is paid or care is approved.
- Follow up with your insurance company. Many appeals take weeks, even months, so call often to check the status and take notes of each call.
Most insurance companies have at least a three-level appeals process. Appeals at the first level are usually processed by the company's appeals staff or by the company's medical director responsible for the denial. Second-level appeals are reviewed by a medical director not involved in the original claim decision. And the third level usually involves an independent, third-party reviewer, along with a doctor who is board-certified in the same specialty as the patient's doctor.
If your appeal is elevated to the third level and the insurance company continues to deny the claim, you can then take the appeal to the state level. Processes vary by state; you can contact your state's insurance department for details.
If you feel too frail or overwhelmed to pursue an appeal yourself, nonprofit groups like the Patient Advocate Foundation can provide guidance for free. Fee-based services like Health Proponent are also an option. The service has been experimenting with different fee structures and is joining with affinity groups, like alumni associations and the American Automobile Association, to broaden its membership.
Health Proponent charges $29.95 a year for individuals and their families to join and charges additional fees, depending on the type of service it provides. If you have a claim denied, for instance, it will research the problem for a flat fee of $99. (That means using the service for claims of less than that amount doesn't make sense.)
If you have uncovered medical bills totaling at least $400, the company will attempt to negotiate a reduced bill (there's no upfront charge for the service, beyond the annual membership fee).
The service previously charged an hourly rate for this service, Mr. Rosen said, but has switched to a percentage fee. If the company can't negotiate any savings, you pay nothing to Health Proponent; if it does get the bill reduced, you pay 25 percent of the savings as a fee. (Say you are billed $10,000 which is not covered by your insurance, and the company negotiates the amount down to $5,000 - half the total. You pay $5,000 to the provider, plus a fee of $1,250 to Health Proponent. So you pay a total of $6,250, a savings of about 38 percent.)
Have you appealed a denied health insurance claim, with or without paid assistance? What was the outcome?
Your right to appeal a denied claim was expanded under the Affordable Care Act. Now your insurance company is required to tell you why your claim was denied, and you have up to six months to appeal.
" MORE: 5 reasons your health insurance plan will deny your medical claim
You can maximize the chances that your appeal will be successful by following these tips.1. Understand why your claim was denied
Before you can fight a denied claim, you need to understand why it was denied. Your explanation of benefits (EOB), a standard form sent by the insurance company whenever your claim is approved or denied, uses codes to explain how the company arrived at its decision. Most EOBs will also provide a key to the codes, so you can find out what they mean. If you still aren't sure why the claim was denied, call the company and ask. You have a right to this information, and the insurer has a responsibility to explain it in terms you can understand.2. Eliminate easy problems first
Sometimes your claim was denied only because of a data-entry error like a misspelled name, insurance ID number, or the wrong date of service. Read through all the documentation from your insurance company carefully and look for errors. If you find one, ask the insurance company to correct it before you proceed. If it was an error on the part of your medical provider, ask her to correct the problem and resubmit the claim.3. Gather your evidence
Make sure you have all the evidence to show that the services you want covered are medically necessary. Referrals, prescriptions from your doctor and any relevant information about your medical history may help your claim get approved the second time around. You or your doctor will also want to reference your health plan's medical policy bulletin or guideline for the treatment you received. These are often available online through your health plan's website.4. Submit the right paperwork
You may need to write a letter to your insurance company. If you do, make sure to include your claim number and the number on your health insurance card. But your claim may be processed faster if you use the insurance company's standard appeals form. The explanation of benefits you received should tell you how to appeal the decision, or you can call your insurance company directly and find out how to appeal.5. Stay organized
The insurance company has its own internal system for tracking your medical claim and any subsequent appeals. You have to be just as organized to make sure you're following up on any detail that may make the difference. Keep all your paperwork in one place and take careful notes during every phone call with the insurance company. Ask for the name and the job title of the person you're speaking to and write down the date of the conversation and any next steps. You should also ask for what's termed a "call reference number," and if an appeal was submitted, get the "document image number." This information will help you build your case and ensure that the next customer service agent you speak to can quickly access all the necessary files to help you move the appeal process forward.6. Pay attention to the timeline
It's easy to call the insurance company once and then forget about it, but you have to follow up. Set up a system to remind yourself to follow through. If a customer service agent tells you he is going to resubmit your claim and it will take about a week to be processed, make a note in your calendar to call back in a week to check on the status. The company is more likely to move your claim through the pipeline if you apply a little gentle pressure.7. Don't shoot the messenger
Having a claim denied is scary. If you're waiting for pre-approval before you can have tests or a necessary procedure, it can be even worse. But don't forget that the person on the other end of the phone is probably not the person responsible for denying your claim. She might be a valuable ally, so treat her with courtesy and respect. If you find yourself getting upset, explain that you're very concerned about your case but you know it's not her fault.8. Take it to the next level
Until now, you've been appealing the decision directly with your insurance company. But if your claim is denied a second time, you may have one more chance to change their minds. The Affordable care Act requires that states set up an external review process for denied medical claims. Check the Centers for Medicare and Medicaid Services site to see whether your state has implemented the new guidelines yet.9. Speed things up
If you need medical care urgently, you may not be able to wait for the company's internal appeals process to run its course. "You can file an expedited appeal if the timeline for the standard appeal process would seriously jeopardize your life or your ability to regain maximum function," says Healthcare.gov. In such cases, file internal and external appeals simultaneously. If you're too sick to take care of this on your own, your doctor can file an external appeal on your behalf.MJ Columbus OH July 12, 2011
Unfortunately sometimes the only way to get around denial of precertification is to ask your doctor to lie. I had an MRI after a fainting episode that showed possible MS, which runs in my family. All other diseases were excluded. The medical recommendation is to get a follow-up MRI in 6-months. Because I wasn't having active symptoms, the follow-up MRI was not pre-certified when ordered by my neurologist. I went to my family physician for help, she requested the MRI, saying I was having headaches (everybody gets one occasionally, right?). I immediately got the necessary MRI and am now being treated. I think the insurance company didn't really want to deny the MRI, they wanted to delay expensive treatment, which was the likely outcome.
I live in the communist state of New York and think it has much to recommend it, despite the high taxes.
First, we have some rent regulated apartments in New York. Despite the fact that free marketeers howl, it does serve to preserve a small amount of social diversity (and even though rents overall arguable might be cheaper, the regulated apartments are a historical artifact and do not affect new development, which has been considerable).
Second, if you have a health insurance plan with a New York insurer, you have the right to external appeal (as in you write a letter to the state insurance bureau, they send it off to a doctor with relevant expertise to determine whether the insurer is in fact within its rights to deny the claim. I have used this more than once, including times when the insurer tried denying coverage MANDATED by state law.
And if I had had no right of external appeal, my only recourse would have been to sue them (and lawsuits in general are uneconomical unless you have, say, $150,000 or more at issue. I have found the external appeals guys have very little patience with health insurer BS, which is refreshing).
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How to appeal an insurance company decision HealthCare.gov
Tips for Appealing a Denied Health Insurance Claim - NerdWallet
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