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Appealing Health Claims

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The following is taken from Parade Magazine's January 2008 article, "Fight for Your Health Care," by Lori Andrews, and is still a great guide that we recommend for anyone struggling with denied health claims.


Chances are, you will eventually have a health insurance claim rejected. And even if that decision appears arbitrary and unfair, you may just roll over and accept the verdict. Fighting the health-insurance bureaucracy on even small matters can be draining. And winning may seem like such a long shot..


But that really is not true. Surprisingly, people who fight back when their health-care provider says “no” often do win. The keys are knowing what will get results and being persistent. Whether your health plan is a traditional insurer, a PPO or an HMO, and whether it dismisses your claim or agrees to pay only part of the bill—here are the steps to take:


1. Know Your Rights


When coverage is denied for a treatment or drug, it is up to you to collect information and make the case for coverage. This is true whether you are seeking pre-authorization before you receive a service or are disputing an Explanation Of Benefits (EOB) form sent to you in response to an unreimbursed claim.  


First, check your rights under your health-care plan and under state law. If your employer provides your insurance, call your human-resources department to get a copy of the policy. Read it carefully. The policy will tell you what is covered and what mechanism you can use to challenge your health plan’s decisions. If you don’t understand the provisions, ask someone in human resources for help or call your insurer’s customer-relations number for an explanation.  


Health plans are required to follow state and federal law for handling complaints and appeals. Find out your own health plan’s internal review process, then follow it.


2. Contact the Insurer


Get your paperwork together before you call the health-plan insurer. (You will find the phone number on the form that was sent to you with denial of your request for reimbursement. It also will be on your policy.) Be prepared to lay out all the evidence to convince your insurer that your position is correct.  


Your dispute may be resolved with your first informal call, but that call also may be the start of a lengthy process. Make a file and start keeping accurate records of every contact you make: whom you spoke with, the date of the conversation, what was said and when they said the next step would occur.


3. File a Written Appeal


If you don’t get results from a phone call, file a written appeal with the health plan. To prepare the appeal, request a copy of your entire claim file from the health plan, advises Jennifer C. Jaff, an attorney who is the executive director of Advocacy for Patients With Chronic Illness. The file will include the plan’s specific rationale for rejecting your claim. Tailor your letter to the plan’s criteria for denial or acceptance and attach supporting documents.


If the claim file says the treatment was “unnecessary,” attach your medical records. These should include test results and an explanation of why other treatments have failed as well as a letter from your doctor about why you needed that treatment.  


If payment for your treatment is declined as “experimental,” you’ll have to show that the procedure you had is now medically accepted. You can do this by searching on the Internet or at your public library for articles in medical journals that demonstrate the effectiveness of the novel treatment you are trying to get covered.  


Make sure you file the appeal within the designated time limit. Some plans, for example, require that you challenge a reimbursement denial within 60 days. The two biggest mistakes patients make in their appeals are not providing enough background material to justify coverage and not meeting deadlines.


4. Get Outside Help


If you have a chronic condition such as diabetes or cancer, or even a rare condition such as Crohn’s disease, the advocacy organization devoted to that disease can help you frame your appeal. For example, the website for the American Diabetes Association,, provides information for people who are having trouble getting health-care coverage. Although the website is targeted to people with diabetes, the advice is helpful for all patients.


5. Demand An Independent Review


Starting in 1990, managed-care enrollment in the U.S. increased by 85%. As more patients signed up, more of them also began to complain to their legislatures about denials of coverage by their health plans. State lawmakers listened: 43 states plus the District of Columbia have enacted some version of a Patient’s Bill of Rights. As a rule, these laws give consumers the right to an independent medical review when a health plan denies coverage for care or access to out-of-network providers.    


But few people make use of these mechanisms. In Illinois, where about 1.5 million people are enrolled in HMOs, only one in 225 members a year files a complaint with the HMO. Far fewer—one in 2250—take the appeal to the next level by asking for an independent review of their claim.  


That’s a mistake. Although success rates differ from state to state, consumers tend to prevail in these challenges about 50% of the time. Health-care insurers made profits in the billions last year. Know your rights, so profits will not be taken unfairly from your own benefits.


6. Help Change The System!


Even after you’ve won the right to be reimbursed, other members of your health plan could be denied reimbursement for the exact same procedure. Here’s how to help state lawmakers bring about change:


Get the insurer to do the right thing. Let your state legislators know that an independent medical review found in your favor. If lawmakers see that a company repeatedly denies payment for a particular procedure (but then reimburses only those who complain loudly enough), the state could pressure the company to cover the service for everyone. Some consumer groups have persuaded state legislators to pass laws mandating certain services. As a result, at least 15 states now require insurers to cover some infertility treatments, 20 states cover speech services, and 46 cover diabetics’ supplies.