Appeal Denial Countermeasures

1) The first thing to do is find out why the claim was denied. For health insurance this should be on a form called the "Explanation of Benefits." If you do not have this form, contact the company or your agent/representative; in most states this form is required.

The usual rejections are:
The plan did not authorize the treatment,
The doctor, hospital or provider of the services coded the claim incorrectly,
Your insurance company deemed the treatment as not necessary,
The treatment is regarded as experimental,
The plan you have specifically excludes the treatment.

If you do not have written notice of the denial, contact your insurance company and ask for one. You need this documentation to process an appeal. If you do not have a copy of your policy get one from your insurance company.

2) Get help: Other than hiring an attorney here is a site on the Internet that will assist you with information.

Call (800) 532-5274 or go to:

**Webmaster's Note: We highly recommend this site for information about the following topics, among others: ACCESS TO CARE: Insurance Appeals Process; Expedited Appeals Process; Access to Pharmaceutical Agents; Expedited Application for Social Security Disability, Medicare, Medicaid, SCHIPS, and other social programs;

JOB RETENTION: Family Medical Leave Act (FMLA) qualifications; Disability accommodations; Communication with the Equal Employment Opportunity Commission (EEOC) and state Fair Employment Practices Agencies (FEPA); Denial of Income; Denial of Health Benefits; and DEBT CRISIS.**

3) When you address your appeal to the insurance company, these tips might help you.

a) Medically Unnecessary:
Provide statistics showing the procedure may extend or improve the quality of life. Get statistics from clinical trial(s) that could bolster your case.

b) Experimental Procedure:
You must prove otherwise. Enlist your health-care provider and attorney in this. You can cite studies published in reputable medical journals that support your position.

c) Excluded Coverage:
You can file a “compassionate appeal” citing facts to support exceptions. You have nothing to lose by doing this.

These same principles would apply to private disability insurance as well.

IMPORTANT:
You must do the appeal work; enlisting your doctor to file an appeal is not very successful. Insurance companies want facts to make an exception. Most doctors discuss medical ethics and give a medical opinion, which is not helpful in an appeal process. These companies want factual proof to change their policy.

Last modified: 2003