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Health Insurance Appeals

Locate medical experts and find information on insurance coverage and financial assistance for risk management, treatment and follow up care.

How to file an appeal

If an insurance company doesn’t cover a service, you have the right to appeal the decision. Insurers sometimes deny preventive services because they argue it is not medically necessary. In this case, you can appeal the decision and make the case that the screening, preventive or prophylactic measure is medically necessary. A letter from your doctor can help support your argument.

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. To assist our community with insurance denial appeals, FORCE has created sample insurance appeal letters on the following screening and preventive services indicated for the hereditary cancer community (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.

State external reviews may be a good option if you were denied preventive or prophylactic treatment based on a lack of medical necessity. If you can show that the preventive treatment is medically necessary, then there is a greater chance of winning the appeal. In this process, doctors and other health care professionals can be a great help in presenting evidence. If an external review finds in your favor, the insurer usually must follow their determination, although the specific rules vary state by state.

Additionally, healthcare.gov has information about health insurance appeals and health care reform. You can call the Cancer Legal Resource Center at (866) 843-2572 or the Patient Advocate Foundation at (800) 532-5274 for more information about federal and state-specific insurance laws.

Updated 03/11/16

 

FORCE:Facing Our Risk of Cancer Empowered