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 ita medication or procedure that requires certain criteria to be metbefore the insurance company will pay? or is it an item that isspecifically listed as not covered, such as a hot tub or footorthotics? If you are not sure, call your insurance company and askthem. Remember to write down the names of people you speak to.
It is often more difficult to obtain approval for a specificallyexcluded item or service, because there are usually no provisions forcoverage of those things in your policy, regardless of why the item isneeded. If you really feel that your case warrants an exception, besure 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 herarthritis") and send in any information about alternatives you havetried, and why this particular item or service should be covered. Eventhen, do not be too surprised if your request is denied.
4.Requests for coverage of some items or services are denied because thepatient did not meet the criteria for coverage, sometimes called themedical necessity guidelines. If you or your doctor receive a letterwhich references criteria or guidelines, call your health insurancecompany and request a copy of the criteria before you begin yourappeal. Also request a copy of all the information they reviewed inmaking their decision, so you can see what they based their denial on.Many times, it is simply that the complete information about yoursituation has not been submitted.
5. Review the medical necessitycriteria with your doctor to find out if you meet the guidelines. Ifyou do, have your doctor submit a detailed letter outlining how youmeet the criteria and have her include all of your relevant medialrecords. If you do not meet the criteria, but your doctor still thinksyou require the service or item, have her explain in the letter to theinsurance company why coverage should be approved - maybe there is anew study out, or maybe your situation is rare. The more detailedinformation your doctor can provide, the better chance at approval youhave. You should also send in a letter on your own behalf, explaininghow your condition is affecting your life, treatments you have tried,and other doctors you have consulted.
6. After you've filed yourappeal, you should receive an acknowledgment letter from your healthinsurance company with the name of the person coordinating your appeal.Call that person, introduce yourself, confirm that they have receivedall the information you sent in, ask them if additional information isrequired. Some insurance companies will allow you to attend a meetingto present your appeal in person, ask if this is allowed, and considerdoing it. It will allow the people making the decision about yourappeal to meet you in person, instead of just on paper and this canoften make a difference.
7. If, after going through the appealsprocess, coverage is still denied, find out what other options areavailable to you. Members of many insurance plans in Massachusetts havethe option of an outside review by an independent agency selected bythe Office of Patient Protectionif the request for coverage of an item or service was denied based onlack of medical necessity or failure to meet certain criteria. Externalreviews are not provided for those items or services which arespecifically listed as excluded from coverage.
For more information regarding managed care plans in Massachusetts, click here.