En español | When an insurance claim for your loved one is denied, there are steps you can take to appeal the decision. Medicare, Medicaid and private insurance companies all accept appeals to denied claims. The process can be confusing and, at times, time-consuming, but it can also be well worth it. Here is a breakdown on how appeals work for each.
Regardless of your loved one's Medicare plan, recipients have the right to challenge any denied payment or service that they feel should have been covered or offered. The process differs based on the type of Medicare plan, but each plan's process is straightforward and easy to understand. Here are the basics of each:
- Original Medicare: If Medicare didn't cover a test, doctor's visit or any other service you feel should have been covered, whether in part or in full, gather any documents from your loved one's doctor that may bolster your case and file an appeal. The directions on how to file can be found on the back of the Explanation of Medicare Benefits or Medicare Summary Notice you or your loved one will get in the mail, along with details on why something may not have been covered.
- Medicare Managed Care Plans: Under these plans, recipients and their caregivers who feel that a service should have been paid for, whether in part or in full, or feel they should receive a service they were denied, should file an appeal. Also, an appeal should be filed if a Medicare managed care recipient feels a service that should be covered or provided was stopped short.
Fast decision options are offered to those who believe their health could be compromised while awaiting a decision and are answered within 72 hours.
Directions on how to appeal are provided, in writing, by the Medicare managed care plan. Review your membership materials or call your loved one's plan for more information.
If, after review, your loved one's plan sticks with its original decision, all is not lost. The appeal will then be reviewed by an independent organization working for Medicare.
- Medicare Prescription Drug Plans: If a Medicare prescription drug plan recipient is denied a Part D prescription drug, or coverage of a Part D prescription drug, by a plan sponsor, and the recipient believes this has been done in error, an appeal should be filed. As with Medicare managed care plans, the directions on how to appeal are provided, in writing, by the plan. Standard appeals must be addressed within seven days after the request is received. Fast appeals can be requested by plan recipients, or their caregivers, who feel that their health will be adversely affected by waiting seven days for an answer. If granted, plan sponsors must answer the appeal within 72 hours of receipt. If the plan sponsor opts not to change its stance on your coverage despite the appeal, there are additional steps that can be taken. Review your loved one's plan sponsor's membership materials or contact the plan sponsor by phone for a full explanation.
For a full explanation of the Medicare appeals process for all plan types, visit Medicare's website. Go here for appeal forms.
As with Medicare, any recipient of Medicaid has the right to appeal any denied payment or service. First, contact your loved one's Medicaid case manager, who will help guide you through the appeals process. It begins with either a call or a letter to the Medicaid appeals representative for your loved one's area. If the issue isn't resolved over the phone, an appeals form will need to be filled out including the reason for your appeal along with all of your loved one's Medicaid information. Include a letter from your loved one's doctor stating the necessity of the service or procedure as well as any scientific evidence you can find backing up your appeal. After receiving your appeal, Medicaid's decision can take up to three months. For more information on this process, visit Medicaid's website.
Next page: Handling private insurance appeals. »
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.
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