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Dealing with an injury or illness is stressful for the patient as well as the family. When you or a loved one are denied a medical procedure or therapy that has been performed or requested to be performed by your treating physician, it can be very stressful and become a crisis situation. The following are suggestions on how to navigate the appeals process.
Simply stated, a “denial” means that the insurance company has decided not to pay for the procedure or therapy that your doctor has recommended. The procedure or therapy may have already been performed or may be scheduled in the near future. If the denied procedure has not yet been performed, the insurer may be denying the request for preauthorization.
“Preauthorization” means that the insurer has given approval for a member to receive a treatment, test, or surgical procedure before it has actually occurred. The goal of the appeal-process is to allow the patient to be heard and provide any and all necessary information to convince the insurance company to change it's decision and provide coverage for the procedure.
When submitting your appeal, keep in mind that the best defense is a good offense. In other words, it is generally better to take the time to gather all the necessary information and submit a well thought-out appeal packet than to hastily submit a response and miss the opportunity to educate the insurance company about your specific situation. There are several steps you should take to produce a thorough appeal packet.
The six primary steps to navigating the appeals process are:
1. Know the rules and procedures to follow.
2. Summarize the problem or situation in writing.
3. Always document the sequence of events as they occur.
4. Communicate clearly, concisely,and calmly.
5. Always insist on specific details: how, when, who, where, and how much.
6. Be persistent if your grievance is not resolved to your satisfaction.
For more information on the appeals process go to:
www.patientadvocate.org
1. Know the rules and procedures to follow.
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As a first step, enrollees are usually encouraged to call the plan's customer service representative or benefits manager with questions or to voice concerns.
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Obtain a copy of the plan's description of the coverage and grievance process from your plan's benefits manager. This is known by different names in different plans ranging from "Your Health Benefit" to "Your Health Care Coverage". Steps to be followed in the appeals/grievance process are usually explained in writing as part of your policy.
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Instructions for submitting a complaint in writing should be in your plan's description of the coverage and grievance process. If any of these instructions are omitted from your policy or you cannot get the complete information from your insurer, contact the state insurance commissioner's office to get clarification on the procedure to follow to procure the proper instructions.
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A simple letter to your insurer about denied services, as well as a statement of your intent to appeal, is generally sufficient to set this process in motion. The letter should be sent to the person or persons issuing the denial. Retain a copy of your letter and follow up in a few days with a phone call to ensure receipt of your letter.
2. Summarize the problem or situation in writing.
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Describe the problem and what you think the solution should be.
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Ask your treating physician to write a letter of appeal to the insurer to accompany your letter.
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Refer to this summary as a guide when you call the plan representative. Request a written response within 10 working days, as well as a phone call confirming receipt of your letter.
3. Always document the sequence of events as they occur.
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Keep written, dated, chronological notes on file from the beginning of the appeal. This helps you stay organized and is a useful reference.
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Be sure to document all contacts with the managed care plan representatives. Get the name, title, and phone number of each person with whom you talk.
4. Communicate clearly, concisely, and calmly.
- Be persistent, and remember that your goal is to get them to accept your solution.
5. Always insist on specific details: how, when, who, where, and how much.
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If a resolution is promised to you, ask for details in writing, such as a specific date by which your grievance will be resolved. If you do not understand, ask for clarification.
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Ask whom you should contact if you do not receive acknowledgment of your appeal in writing.
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Ask when and where you will have your grievance heard and ask how long it will take for a final decision. Ask who may attend the meeting, including your physician.
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Remember the cardinal rule: Always write down the name, title, date, and phone number of all parties you speak with at the insurance company.
6. Be persistent if your grievance is not resolved to your satisfaction.
About the Patient Assistance Program
The Patient Assistance Program provides medically necessary therapies to qualified patients who are uninsured, underinsured, or for those individuals who cannot afford their prescribed therapy.
Assistance in Obtaining Insurance Coverage
A list of sites that are a direct link to insurance coverage options relative to chronic disorders. |