Private Health Insurance
There is no universal process for appealing a claim that has been denied by a private health insurer. If coverage of a private health insurance claim has been denied, here are some tips to get you started on the appeal.
- First, find out why your loved one's insurer denied coverage. It could be something simple, like a clerical error at the doctor's office. In some cases, simple errors can be righted over the phone.
- If you're not one of the lucky ones whose problem can be solved quickly over the phone, find out how your loved one's insurer handles appeals for denied claims. Often, this can be done by contacting your loved one's insurer or reviewing their policies online. Either way, be sure to take specific notes because the process to file an appeal can get confusing. And take down the name of every representative you speak to and note it next to the information he or she gave you. Unfortunately, you may get different information based on who answers your call. These notes may come in very handy when you write up your appeal.
- Once armed with the appeals process, it's time to dig in and do your homework. Request from your loved one's insurance company the following documents:
o Letter of denial.
o Evidence of coverage.
o The insurer's guidelines for what they consider to be medically necessary.
- Next, research the procedure or service that was denied to find out if it is, in fact, medically necessary for your loved one's condition. Sometimes, proving the medical need for a procedure or service can result in a reversal. Your loved one's doctor can likely provide a letter on his or her behalf stating the necessity of the procedure or service.
- Look into scientific evidence that can further show how this procedure or service has helped others with your loved one's condition. Sometimes insurers will deny coverage for something they deem "experimental" when a procedure is new to the medical community. If there is scientific evidence of its efficacy, however, you may have a case. A good resource is PubMed.gov.
- If after all of your attempts the insurer is still denying coverage, consider reaching out to a nonprofit group such as the Patient Advocate Foundation, which can help you and your loved one sort through your options. The state insurance administration where your loved one resides may also be a good resource.