Health Insurance Appeals

You spend a lot of money on health insurance, and expect it to cover those things you need. Well, if you’ve read your benefit booklet (and who hasn’t?), you know that there are plenty of things that are not covered, and more things that are only covered in certain circumstances. It can be frustrating and scary to have your health insurance deny coverage of an item or service your doctor is recommending to you or a loved one.
If the times comes when you need to file an appeal with your health insurance company to obtain coverage of a needed item or service, here are some guidelines for doing so:
1. Find your member handbook. If you don’t have it, request a current one from your employer or call the health insurance company for a copy.

2. Read the member handbook. Review the section on what is covered, and then the section on what is not covered and see if you can find a mention of the item or service you need. Finally, read the section on filing Appeals. Find out how many levels of appeal there are, and if there is an external appeal option to an outside agency.  If you don’t understand something about the appeal process, call your health insurance company and ask them to explain it.

3. Determine why coverage of the item or service has been denied. Is it
a medication or procedure that requires certain criteria to be met
before the insurance company will pay? or is it an item that is
specifically listed as not covered, such as a hot tub or foot
orthotics? If you are not sure, call your insurance company and ask
them. Remember to write down the names of people you speak to.
   
It is often more difficult to obtain approval for a specifically
excluded item or service, because there are usually no provisions for
coverage of those things in your policy, regardless of why the item is
needed. If you really feel that your case warrants an exception, be
sure to have your doctors write a letter (and one which says more than
"It is medically necessary for Jane to have a hot tub due to her
arthritis") and send in any information about alternatives you have
tried, and why this particular item or service should be covered. Even
then, do not be too surprised if your request is denied.

4.
Requests for coverage of some items or services are denied because the
patient did not meet the criteria for coverage, sometimes called the
medical necessity guidelines. If you or your doctor receive a letter
which references criteria or guidelines, call your health insurance
company and request a copy of the criteria before you begin your
appeal. Also request a copy of all the information they reviewed in
making their decision, so you can see what they based their denial on.
Many times, it is simply that the complete information about your
situation has not been submitted.

5. Review the medical necessity
criteria with your doctor to find out if you meet the guidelines. If
you do, have your doctor submit a detailed letter outlining how you
meet the criteria and have her include all of your relevant medial
records. If you do not meet the criteria, but your doctor still thinks
you require the service or item, have her explain in the letter to the
insurance company why coverage should be approved – maybe there is a
new study out, or maybe your situation is rare. The more detailed
information your doctor can provide, the better chance at approval you
have. You should also send in a letter on your own behalf, explaining
how your condition is affecting your life, treatments you have tried,
and other doctors you have consulted.

6. After you’ve filed your
appeal, you should receive an acknowledgment letter from your health
insurance company with the name of the person coordinating your appeal.
Call that person, introduce yourself, confirm that they have received
all the information you sent in, ask them if additional information is
required. Some insurance companies will allow you to attend a meeting
to present your appeal in person, ask if this is allowed, and consider
doing it. It will allow the people making the decision about your
appeal to meet you in person, instead of just on paper and this can
often make a difference.

7. If, after going through the appeals
process, coverage is still denied, find out what other options are
available to you. Members of many insurance plans in Massachusetts have
the option of an outside review by an independent agency selected by
the Office of Patient Protection
if the request for coverage of an item or service was denied based on
lack of medical necessity or failure to meet certain criteria. External
reviews are not provided for those items or services which are
specifically listed as excluded from coverage.
For more information regarding managed care plans in Massachusetts, click here.