Filing Appeals for Insurance Denials

• You should keep a record of all letters that you receive and a log of all telephone calls that you make or receive related to the denial. Be sure to write down who you spoke to and the date.
   
• Get a copy of the denial letter. This should give a specific reason for the denial. If you have Medicare, look at your Medicare Summary Notice. Find item 10 - Non Covered Charges.
   
• Call your doctor and request a copy of all information that was submitted to your insurance.
   
• Call your insurance company and get a copy of your plan document (policy), plan summary or health insurance booklet. If you have Medicare call 1-800-Medicare and request "Medicare and You" booklet.
   
• Get specific names and telephone numbers of contact people. You may have to call your insurance company and ask for a contact person. Be sure to get their direct line. Get the address where you send your appeal, this may not be the same address for the initial claim submission. Also have someone at the physician's office or facility that will help you with the appeals process.

If you have Medicare, remember you always have the right to appeal decisions that deny or limit payment for medical care. Consult the back of your Medicare Summary Notice for more information about your appeal rights. Private insurance will have a written process you must follow to appeal the denial. You may find this in the plan document, it may be on the denial letter or you may have to request this from the insurance company.

If you still do not understand your rights or the appeal process is unclear, and your employer or insurer will not or cannot explain further, it may be helpful to contact an attorney.

• Read your policy before you file an appeal to ensure you understand your coverage.
   
• Find out why the claim was rejected.
   
• Follow the appeal process outlined by your health plan. You may need to get a letter from your doctor/specialist addressing the specifics of your case. You may need to write an appeal letter and include copies of your medical records.
   
• Be sure to follow all time limits that are outline in the appeal process for your health plan. Timely follow-up can make all the difference in the world.
   
• When writing your appeal letter, indicate the date, claim number, date of service, your member identification (subscriber) number, group or policy number, amount of charge, and medical provider name.
   
• Don't give up. If you receive a second denial, you may consider continuing with the appeal process. Most plans have several levels of appeal.
   
• Keep copies of all documents that you submit to the insurance company. You also might send the documents registered mail, return receipt requested.

In some cases it may be helpful to contact an attorney. Many people would rather appeal the denial on their own to see if they can over turn it without legal help and expense. It may also depend on the cost of the procedure. Your state or local representative may also provide assistance in resolving insurance issues. You may access a list of legislators at the National Patient Advocate Foundation website: http://npaf.org/. It may also be beneficial to contact the State Department of Insurance. One of the main duties of the insurance commissioner is to make sure the health plan is following the patient's policy.

Since each insurance is different, it is impossible to write a fail proof plan for overturning a denial. Reviewing your plan policy, documenting your conversations and actions, staying organized and focused all will assist you in obtaining the outcome you desire.