HOWTO: Appeal Denial of Care

We all know that health insurance companies are evil. What we don’t know is what to do when our evil health insurance company denies our claim.

If you don’t have time to call John Grisham and ask him to write a bad legal thriller about you, you might want to brush up on these strategies for appealing a denial of care judgment.

• Follow the companies procedure for referrals and appeals. Understand your coverage! This will save a lot of time and pain.

• Appeal through your plan. Companies may have different procedures for different kinds of appeals. Learn the rules and stick to them.

• If you’re not satisfied with the internal appeal process, get an external review. External review programs vary by state to state, so learn the rules in your neck of the woods. Good luck with your gastric bypass.

[Consumer Reports]
[KFF.org]

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  1. Old Hag says:

    Also, don’t forget your state’s insurance administration (is that what you mean by “external review”?). They have complete jurisdiction over any insurance companies practicing in your state, and appealing anything is free. The internal bureaucrats at the administration sometimes give you static and deny your request for a hearing, but you can appeal that too, and should, until you get to a judge. Once you have a hearing scheduled, it’s usually not cost-effective for the insurance company to trot out a lawyer, and they go ahead and pay you.

    Don’t underestimate the extent to which insurance companies are banking on you giving up–and don’t forget that your tax dollars are paying for an organization that does protect you.

    Also, copy your local representative on everything; it irritates everyone and they push your case up.

  2. chickymama says:

    Follow up with the insurance comapany within 30 to 45 days of sending your appeal. I appeal insurance denials for a living and there are certain insurance companies that are notorious for not receiving the written appeal (Cigna and Blue Cross Blue Shield). To ensure they have received it, send it in certified, return receipt and do not get off the phone until they find it when doing a follow-up.

    Remeber these three words: document, document, document. This was grilled into me by my instructor. Your word will mean nothing.