Filing an Appeal

Many individuals believe a denial letter is the "end" of the road when it comes to insurance company responsibility for a medical claim. Just because a claim has been denied, no matter the reason, does not mean you have to take it lying down.

Most medical claims are denied for a wide variety of reasons. Failure to find out why a claim was denied frequently means the difference between getting the claim paid by the insurance company or individuals paying the bill out of their own pocket. It is a little known fact that many insurance companies will often deny a first request for approval hoping individuals will give up. This is especially the case with high dollar medical equipment, palliative care, and other treatments specifically identified by the insurance company. By following the approved appeals process many individuals obtain the services or equipment they need. Always appeal a denial.

It is important for you to be familiar with the appeal process required by your insurance company. Not all companies have the same appeal process. Most companies include a section in their manual on "How to File An Appeal". Many companies include that information on the back of the EOB, or in the fine print of any bills you receive. If you check these resources and still cannot find instructions call the Customer Service number and specifically request information on how to file an appeal.

There are seven basic steps in filing an appeal. Each step is important and should be followed in order.

Step One: Review your Benefits and Policy Manual. The first step in launching a denial appeal is the same as filing the claim in the first place. Was there something there that you missed? Did you read the fine print? Are you sure of the detail? Did you need a preauthorization and fail to get one? Having a firm understanding of your policy will help you know what questions need to be asked.

Step Two: Contact your Insurance Provider. If your claim has been denied be certain it was denied by the appropriate person. Often times insurance company personnel will tell you "no" when in reality they do not have the authority to do so. Be sure the decision came from the right office. Don't take "No" from someone who isn't authorized to say, "Yes". Be sure to document all pertinent information you discuss. I recommend using an SNRP Call Form. Be sure to document all of the following on your call form or in your notes if you are not using a call form:

• Company name
• Date and time of the conversation
• Name and title of the person you talked to. Be sure to note any other individuals you may talk to during your call.
• Account number and any questions you may have regarding the claim in question.
• Write a detailed summary of what was discussed and any instructions or information you were given.
• Write a short summary of any decisions or agreements reached.
• Be sure to add your signature to the bottom of the page, as this will allow reviewers to know whom the conversation was recorded by and provided the information. This could always be used as a legal document later, if needed. Information on this document may be used as part of the documentation packet submitted with your appeal letter. Remember. "If it isn't on paper, it didn't happen".

Step Three: Ask for help. You may need further assistance in proving your case. If so, contact your Primary Care Physician, tell them your are appealing a claim denial and need assistance. Ask for a more detailed letter of medical necessity, medical records or any other information that may be requested by the insurance provider that will aide you in stating your case.

 Need more help? Contact your employer's Human Resources Benefits Coordinator and ask for assistance in mediating an insurance claim denial. These coordinators are often good at reading the fine print and assisting employees mediate difficult or complicated medical claims. 

Step Four: Write your letter of appeal. After you have contacted your insurance company and you understand what information you need it's time to sit down and write a letter requesting an appeal. Be sure to be clear and concise. State you are requesting an appeal, and why. Quote the manual when appropriate for reference. This is the time to use the documentation you've been keeping. Copies of phone conversations (completed call forms), letters you may have sent, bills, EOB's, letters of denial, etc. can all be used in the appeal process. Be sure to outline the steps you have taken and list the documents you are attaching for review.

Step Five: Submit your appeal. Once you have gathered all your supporting documentation, asked for help and written your letter it is time to submit your appeal packet. Make copies of all documents in your appeal package. If sending by US Post send the packet with a Delivery Confirmation slip and tracking number. Be sure to file this information with your copy of the packet.

Step Six: Track your appeal! Be persistent in keeping track of where in the process your paperwork is. Many companies will assign an individual case manager to appeal cases. Be sure to stay in touch with your contact person. Don't loose your appeal by letting it "fade into the paperwork pile" on someone's desk. Polite but persistent reminder calls often will speed the process.

With many large companies an appeal could take a few weeks or even a few months. Most folks think, "No news is good news". No news could mean trouble. Ask your case manager if there is a time limit. If a deadline passes and you still haven't heard anything, call and ask for a status, or progress, report on your appeal. The biggest majority of folks who loose out on benefits don't loose them because they are denied it's because they fail to follow through. If you want that bill paid for appropriately you're going to have to follow through until you have that determination letter in your hand. "DON'T TAKE "NO" FROM SOMEONE WHO DOES NOT HAVE THE AUTHORITY TO SAY "YES"."

Step Seven: Document the outcome. Once an appeal has been denied it becomes your responsibility to find alternate resources for funding. Every time you get a denial from someone, KEEP IT! A denial for a medical claim will give you extra leverage when filing for other assistance programs and using justifications for financial assistance. DENIALS ARE GOOD!

I know, I can hear parents groaning about paperwork and bureaucracy but it is often imperative to go through the denial process in order to get other services available. If you want the services you need you have to fight for them. Unfortunately paperwork is a part of the system we have to deal with.

Don't take a denial of medical claims lying down. Always file an appeal!