PROPUBLICA – When a health insurer refuses to pay for your treatment, you may have the right to have the denial reviewed — and potentially overturned — by an independent provider.
Here are six steps experts suggest to help you through the external appeal process.
Gather your information:
Experts suggest not throwing out any letters or notices from your insurer, including denial notices, explanation of benefits, correspondence and plan documents. If you’ve misplaced them, they said you can contact your insurer for additional copies.
They also recommend downloading or requesting your medical records. You can request your claim file, which most people have a right to under federal regulations.
Does your state have a consumer assistance program?
Not all states have consumer assistance programs. Here’s a list of those that do. Advocates recommend reaching out and asking them to explain the denial. It might be as simple as a missing or incorrect code. Their job is to use their time, experience and resources to explain the process. Their services are free. Other programs and nonprofits also offer assistance.
Why were you denied, and what are your timelines to appeal?
Are you being denied because the insurer determined the treatment was not medically necessary or because your plan didn’t cover it? Does your plan follow federal or state regulations? Experts say these distinctions may determine if and how you appeal your denial.
Most plans give you about 180 days from the date of the denial notice to appeal internally, but experts say not to wait. If you’re not sure about the answers to any of these questions, you can call your insurer and ask. They are required to provide you the reason for denial.
Can your health care provider help?
Experts suggest reaching out to your doctor or therapist. They said some providers will file the appeal on your behalf. Others will write a letter of support. At the very least, advocates agree, most should help you understand why your treatment was denied and what additional steps you can take.
Filing an internal appeal:
Before you can file an external appeal, you typically have to attempt to resolve the dispute internally with the insurance company. This step may involve one or two levels of internal appeals.
How to request an external appeal:
This is your last shot before considering a lawsuit …
