APPEALING HEALTH INSURANCE DENIALS
Insurance companies frequently deny care your doctor has recommended by saying it is either not medical necessary, at a higher level of care than is necessary, that you do not have coverage, or that the care is custodial and not medically necessary. All denials should be challenged and appealed.
Additionally, for most insurance policies and plans you also have the right to apply for an external review after you have received an appeal denial from your insurance company.
IT IS CRUCIAL THAT YOU ARE AWARE OF ALL DEADLINES AND TIMEFRAMES AS FAILURE TO TIMELY FILE AN APPEAL CAN FORFEIT YOUR APPEAL RIGHTS AS WELL AS POSSIBLY DAMAGING A POTENTIAL LAWSUIT.
Following are some important points to remember:
1) Have Your Policy: It is crucial that you have a copy of your insurance policy. In addition, if you received your health insurance through your employer you should have received a yearly summary of benefits.
2) Keep Records: Make certain you have the name of any person to whom you speak at the insurance company and all correspondence Note the date and time of all calls and get the person’s ID number and the identifying number of the call.
3) Obtain the Denial Letter: Make certain you have your denial letter since companies often only notify the doctor. The letter is vital since it states the reason for the denial and the date which sets the clock running for all appeals.
4) File the Appeal: IMPORTANT: You should always appeal any denial. It is critical you take advantage of the appeal process since it may be the only chance you have of obtaining your benefits.
IMPORTANT: Even if you have an authorization this does not guarantee the company will pay for the care after it is provided. You must be vigilant in obtaining reimbursement.
If the insurance company denies your care, stating that it is either not medically necessary or experimental, you are entitled to at least one “internal” appeal of your denial and possibly an “external” review. The internal appeal goes directly to the insurance company while the external review, if you are entitled to one, goes to an independent agency.
APPEALING A HEALTH INSURANCE DENIAL: THE INTERNAL APPEAL:
Appeals are critical as they provide the only avenue to get the company to pay for your care without taking the company to court. It is vital that you understand your appeal and that you and your doctor (and attorney, if you retain one) plan this appeal very carefully.
You should have a letter from your physician supporting your appeal and identifying, at the least the following: 1) the nature of your illness, the treatment plan, and why this treatment at this time is medically necessary; 2) the specific medical reasons why the denial is incorrect and why your treatment is medically necessary, 3) the support in the medical literature (ideally pee-reviewed journals and text books) for your treatment, with citations, and 4) what medical harms will occur to you should you fail to have the treatment.
EXPEDITED APPEALS FOR URGENTLY NEEDED CARE:
If the care is urgently needed, you have the right to have your appeal considered in an expedited manner. This generally means that your company must make its decision on your appeal within 24 to 72 hours.
APPEALING A HEALTH INSURNACE DENIAL: EXTERNAL REVIEW:
For most health insurance plans and policies, individuals who have been denied approval for payment for their health care by an insurance company can appeal the denial to an external, independent reviewer. Generally, one must file the request for an external review within four months of the first level internal appeal denial. It is important to take advantage of external review since the research finds that up to one-half of insurance company denials are reversed on external review.
You may also have a second internal appeal but you cannot wait to submit an external review until after your second internal appeal. You can submit both an external review and a second level review but you must submit the external review in a timely manner which is typically before a second level appeal is due.
These independent external appeals are binding on the companies and provide an opportunity to have the care your doctor ordered. However, you must remember that there are strict time deadlines for filing your external appeal. You should consult an attorney to make sure you do not forfeit your rights to these appeals.
SHOULD YOU USE AN ATTORNEY?
It is important to consider having an attorney involved from the beginning of the appeals process. Not only will he/she understand your rights but will be able to gather the proper information, work with your doctors, and present the case to the company or the external reviewer. IMPORTANT: If you do retain an attorney make certain heshe has experience in this area.
IMPORTANT: THERE ARE DEADLINES FOR FILING APPEALS AND CLAIMS IN COURT. YOU SHOULD CONSULT AN ATTORNEY ABOUT THESE TIME FRAMES AND YOUR RIGHTS.
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