Prior to putting your appeal package together, it may help to determine an overall plan or strategy for your case. Answering the following 5 questions may help get you started:
1. Exactly what product or service was denied
You strategy may change depending on the reasons for the denial. For example, if you have been denied physical therapy because you have attended a non-participating treatment facility, your appeal strategy will necessarily differ from a situation in which treatment is denied because physical therapy itself has been deemed medically unnecessary.
- Having a clear understanding of exactly what service has been denied and why may impact how your denial is appealed.
The key reasons given by your insurer for denying your claim are also important factors in determining how to mount your appeal. Your insurer should explain exactly how and why it reached its decision. For example, your insurer should indicate whether your denial was issued because it considers your treatment to be medically unnecessary, or because your treatment is specifically excluded from your coverage plan.
- Understanding why your claim was denied may reveal vital information that may make the difference between a favorable or unfavorable appeal.
Many patients do not review their policy or summary plan description until there is a problem. Patients and their providers should request copies of the policy and review all portions that relate to the services in dispute.
- Understanding the terms and conditions of your policy may help determine if there are grounds for an appeal.
Because a ppeal rights may vary across plans, it is important to understand your particular rights under your particular plan. This information should be contained in your member handbook.
- In order to avoid the loss of any rights, verify any appeal deadlines immediately.
If your healthcare provider expects to win your appeal, it is necessary for them to identify exactly why your denial should be overturned. Since the burden of proof is on the patient, your healthcare provider should assist you in building your case.
- If your provider was advised in error by your plan’s customer service and told that a service would be covered—and you and your provider relied on that information to move forward with treatment—that may be grounds for an appeal. Be sure to gather any supporting documentation you need to make your case.
The type of insurance plan you have often has considerable influence upon the outcome of the appeals process. The following points may be helpful to keep in mind:
- Patients covered by self-insured plans
In self-insured plans, the employer has direct responsibility for medical costs. Appeals in self-insured plans are often overturned in the employee’s favor. - It should be noted that usually all other options with the insurance company must be exhausted before submitting an appeal for review. Patients should contact their human resources department or benefits manager for additional information on their particular plan.
- Patients covered by a Medicaid managed care plan
In Medicaid managed care plans, patients may have special rights in the appeal process that vary from state to state. To obtain more information about rights in your area, contact Medicaid customer service or your State Ombudsman.
- Patients covered by commercial or group health coverage
In this type of plan, the managed care organization has direct responsibility for medical costs. Appeals procedures are usually outlined in the patient’s insurance policy and will follow state law.
In addition to determining your appeal strategy, it may be helpful to become familiar with different types of appeals.