of Insurance Coverage for Medical Treatment
Your childâ€™s health insurance carrier
has denied coverage for a certain medical procedure or treatment. Whatâ€™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
Generally, the insurance plan will
govern coverage. Therefore, itâ€™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 stateâ€™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 stateâ€™s insurance commissioner.
If after youâ€™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 childâ€™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 doctorâ€™s letters have been sent to the insurance
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