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Health Insurance - Your Guide To The Appeals Process

Posted Sep 29 2010 2:26pm

womanplan
The Patient Advocate Foundation

INTRODUCTION

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 precipitate a crisis situation. Since each insurance policy is different, it would be impossible to write a fail proof plan that would work for each patient in all situations. Each patient and each situation is unique. This brochure is designed to help patients and their loved ones navigate the appeal process. It contains suggestions and advice. It should not be interpreted as a substitute for legal counsel.

It is also important to point out that support from your treating physician and specialist is critical. Your physician is the professional trained to assess and recommend a treatment plan for you.

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 pre-authorization. “Pre-authorization” 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 their decision and provide coverage for the procedure. This brochure is also designed to provide a logical approach to the appeal process. 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. These steps are:

1. gather preliminary information

2. understand the illness and the insurance

3. write the appeal letters

4. evaluate the result

When to Consult an Attorney

Credits & Acknowledgements

Click here to view the Appeals Guide in Adobe Portable Document Format (PDF)


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