Health Insurance Appeals and Exception Requests - National Multiple Sclerosis Society

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Health Insurance Appeals and Exception Requests

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Your right to appeal limits or denials for care by your health insurer

Before the Affordable Care Act was passed in 2010, one’s right to appeal decisions made by their health plan varied depending on which state they lived in, their type of health insurance, and whether they bought their own insurance or were covered through a job. In some states, when people disagreed with their health plan’s decision, they could appeal that decision to experts outside of their health plan, and in other states, they had no appeal rights.

When do the the new appeal rights go into effect?

The federal healthcare reform law assures the same level of appeal rights to everyone with private health insurance, if they buy their own policy or get coverage through a group plan provided from their job. For new health plans that you or your employer purchase after March 23, 2010, if you disagree with your plan’s refusal to pay for care, the plan will have to review its decision. And if you still are not satisfied, you will have the right to appeal that decision to an independent reviewer who is outside of the health plan. (If you are in a health plan that you or your employer purchased before March 23, 2010, check with your state insurance department, your employer, and your health plan to find out whether you have similar appeal rights.)

What kind of decisions can I appeal?

You can appeal a plan’s decision not to pay for a benefit, or to reduce or end a covered service, when the plan says any of the following:
  1. The care is not medically necessary or appropriate 
  2. You are not eligible for the health plan or benefit 
  3. You have a pre-existing condition
  4. The care is experimental or investigational
If the plan has told you any of these things and you do not agree, you can appeal. You can also appeal when the plan rescinds your coverage (cancels your coverage retroactively). The plan must give you a notice when it denies payment or rescinds your coverage that explains both their reason, how you can appeal, and any applicable deadlines.

The following are some examples of other health plan determinations or rules you can appeal:
  • Your health plan moves a covered prescription drug to a different tier, and your out-of-pocket costs will go up if you continue to take that drug.
  • Your health plan denies a request for pre-authorization for more sessions with your mental health provider.
  • Your health plan does not cover a prescription drug your doctor has prescribed for you.
  • Although the service, item or equipment prescribed by your doctor was covered by your health plan, the amount you were reimbursed is much lower than you anticipated or think is fair.
  • Your managed care health plan limits your use of health care professionals to in-network providers, but there is no provider in their network that specializes in the type of service you need.

How Can I Appeal a Decision?

If you believe the service, device, treatment, or medication in question should have been covered by your plan, you can and should appeal. Many people do not pursue their appeal rights because they don't believe they can win. But if you are dissatisfied with the outcome of a claim for any reason, you have nothing to lose by taking advantage of your right to request a re-consideration of the original claim. Start by re-examining your plan manual to make sure what you presumed would be covered really is. It is not unusual for people to discover that a medical service or treatment is not covered by their policy. If something is specifically excluded from the policy, chances of winning coverage for it on appeal are slim to none. But if the policy does not mention the specific treatment in question or the coverage is unclear or framed in terms of 'medical necessity', it is to your advantage to try the appeals process.

Carefully review the explanation of benefits (EOB) form (official response to your claim) they sent you. Make sure you understand the reason you have been denied coverage or why you are not being reimbursed more money. These explanations often appear as codes with explanatory notes at the bottom or on the back. Is there a simple explanation, such as, the claim is a duplicate? Is there a mistake in the billing code, patient identification number, date of service or other? If all this information seems in order, your next step is to understand your plan's Appeal Procedures. Look in your manual (sometimes under "Grievances and Appeals"). Follow these procedures carefully, especially the deadlines, as well as these basic guidelines:

  • Write a very clear and simple letter providing the facts and a concise explanation of why you believe your claim should be paid. Keep your letter to one page, but be sure to include your insurance ID number, the specific claim number (if applicable), the name and contact information of your health-care provider, and date of service (if applicable).
  • Keep detailed records of all interactions with your insurer, including names of company representatives you speak with on the phone and relevant dates. Keep copies of claims and bills, appeal letters and any attachments, and any other relevant communications.
  • Follow up. If your appeal is denied, go to the next level of appeal. Do not assume this happens automatically—make sure you communicate your desire for a second-level, or External Review. This will be a re-consideration of your original claim by professionals with no connection to your insurance plan. If the external reviewers think your plan should cover your claim, your health plan must cover it.

Be sure to discuss your insurer's denial, or other coverage issue you are appealing with your physician (or other relevant health care provider) to solicit his/her active support. If the dispute is over the necessity or value of a medical treatment, your physician's support in the form of a letter including studies supporting the benefit of the treatment in question could be invaluable. Provide copies of your appeal letter to your physician (or other provider) for their records. Make sure you do not duplicate efforts. If the dispute is over the medical necessity or value or a medical treatment, your physician is a powerful ally. A physician's letter that refers to scientific studies supporting the benefit of the treatment in question could be invaluable. The National MS Society provides model letters of appeal for a variety of therapies in an appeal letters toolkit for physicians (.pdf) to help you both with the process.

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