Health Insurance: Claims: Appeals

If you are denied the right to get a procedure or treatment or use a drug, or if an insurer refuses to reimburse you:

• Call the insurer immediately. 
• If you have a contact at the insurance company, speak with that person. 
• If your insurer has case managers, ask to speak with one of them.
• If you do not have a contact, and there are no case managers, you will likely be transferred to the first available representative. 
  • If you do not like the person for any reason, ask to be transferred to a different representative. 

When you reach a person who will handle your claim:

• Write down his or her name and extension number.
• Try to make a friend with the person with whom you speak. You will save a lot of time not having to re-explain your situation each time you call. You will also have a better chance of getting what you need. One person sent a photo of herself and her kids to the representative and they bonded as parents.
• Ask for details of why your claim was denied.
  • Perhaps there was a clerical error.
  • Perhaps there was a missing fact that you can supply.
  • If the denial was made after consultation with a medical professional, ask the insurer to send you (in writing) the name(s) and qualifications of the professional(s) who reviewed your claim, together with the medical literature the person relied on. Also ask what the medical professional(s) would suggest instead.
  • Let the person know that the call is not meant to be an appeal. Rather it is an inquiry. Ask the insurer to reconsider your claim.

If you do not receive a positive response within 3 - 5 days, start the following steps, each of which are explained in more detail in other sections of this document.

Step 1. Find out why your claim has been denied if you do not already know.
Step 2. Review the appeal process.
Step 3. Focus on deadlines and company procedures.
Step 4. Consider time tested arguments to prove your case. Focus on obtaining new information to back-up your position.
Step 5. Consult a professional..
Step 6. Obtain support for your position.
Step 7. Look for sources of influence that will help convince the insurer to your point of view.
Step 8. Write a cover letter which is polite but firm.
Step 9. Once you exhaust the insurance company's internal appeal process, consider an external appeal.

If all else fails, consider accessing the legal system and/or complaining to your state insurance department.

Be persistent. Be Persistent. Be Persistent.

• There are studies which indicate that 70% of appeals result in favorable action for the insured. 
• If you decide at some point that continuing to push is not worth your time, stop appealing. That is also a valid choice.

If you are in a Medicaid managed care plan: You may have special rights in the appeal process. Contact the state Ombudsman or Medicaid customer service.

If you receive Medicare: A good source of information is the Medicare Rights Center: www.medicarerights.org , Tel.: 888.466.9050.

NOTE: If the treatment or procedure is vital to your health, consider moving forward with it while you to continue to work to get the insurance company to pay for it. 

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