We’ve heard plenty of horror stories about people’s coverage being denied for situations where they’re darn sure that they were covered, and now, an insurance industry insider has come forward with some tips on how best to make an appeal.
These steps assume that you have gotten treatment and are certain that your policy covered your doctor, service, and diagnosis.
“1. Call the insurance company to get a clear explanation of the denial.
2. If they do not believe it is an error, ask if there is any way that a 1 time “pay and educate” exception can be made to cover it. For many small dollar situations, large companies will make a one time exception without having to proceed further.
3. For denied claims, ask the insurance company the exact reason for denial.
3a. If it is a policy exclusion, they should be able to reference what the exact exclusion is in your policy. If it is truly excluded, the company may have no right to actually pay the claim. Polices represent contracts and paying an exclusion for you can potentially get the insurance company in trouble with the department of insurance.
3b. If the denial is due to the provider not participating with your policy/insurance company, ask if there has been a change in the provider recently. For situations where that has not happened, be sure to include why you believed the doctor to be in your network in your appeal.
3c. If a denial is due to a medical guideline, check with you doctor. You should be able to get guidelines on the exact medical criteria from the insurance carrier, sometimes just from the website. By consulting your doctor’s office, you may be able to provide information to show that you do meet whatever criteria led to the denial.
4. Finally, if the above does not work, be sure to follow the appeal process that is outlined in your policy document. In the appeal, make sure to explain exactly what happened and why you felt the process you followed was correct. In the appeal letter, try to explain your case to show that you understand the process/coverage now and that you would have followed the guidelines if you had known before the service.
5. If your appeal is turned down, follow the steps to continue to the next level appeals process, but make sure to respond to the denial letter with more information rather than just resending the same letter again.
If you follow these guidelines, this should provide what you need for getting a fair shake with the appeals team.”
Thanks, Deep Ears, Nose, and Throat! Have any of you readers been in a situation where the insurance company denied coverage when you thought it was covered? How did you deal with it?