SpecialNeeds.com

Appealing Denials of Insurance Coverage for Medical Treatment

Your child’s health insurance carrier has denied coverage for a certain medical procedure or treatment.  What’s your next step?

Most insurance companies have an appeals process consisting of several levels of appeal.  There usually are time restrictions for each appeal level.  Therefore, it is important to note the time in which to appeal and the method of appeal.  This information is usually printed on the denial letter or Explanation of Benefits document that is sent by the carrier.

Generally, the insurance plan will govern coverage.  Therefore, it’s imperative to review the plan and summary to see whether the procedure or treatment is covered under the plan and whether you have followed the procedures set forth in the plan.  For example, your plan may require a referral from a primary care physician or prior authorization for certain hospital surgeries or procedures. 

Even if the plan does not expressly cover the procedure or treatment, state law may require coverage.  You can contact your state’s insurance commissioner to investigate whether or not coverage is mandated by law.  The National Association of Insurance Commissioners (NAIC) has a website which lists the name and contact information of each state’s insurance commissioner.

If after you’ve reviewed the plan and summary and appeal guidelines, you believe that the procedure or treatment should be covered, call the insurance company and ask to speak to a supervisor.  If the denial is not overturned, you can go through the formal appeals process.  You should contact your child’s doctor and ask him to advocate for your child in the appeal.  Keep records of all communications with the insurance company and make sure that the pertinent medical records and doctor’s letters have been sent to the insurance company.

If the cost of the procedure or treatment is substantial and will offset the cost of legal fees, contact an attorney experienced in health care coverage denials. 

Photo by Matt McGee