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If your insurer refuses to cover the cost of a particular service, you may appeal the insurance company’s decision. To begin an appeal, you should follow your insurer’s internal appeals process. Information about the internal appeals process typically can be found on any claim denial form or in the insurance policy paperwork. It usually involves writing a letter to your insurer asking them to reconsider. It helps to provide evidence of medical necessity. FORCE has sample appeal letters for the following services (click on the link to download the template letter word document):
Sometimes insurers have two levels of internal appeals. If you have been denied in all levels of your insurer’s appeal process, appealing through your state’s external medical review program may be an option. In these programs, an independent group of physicians and professionals reviews your claim and decides whether your insurer must pay. The rules for external medical review vary by state. Most states allow external review in instances when a claim is denied because it was found to be (1) not medically necessary or (2) experimental or investigational. Contact your plan administrator or state insurance commissioner for questions regarding insurance appeals and whether you can appeal through external review.