Denied: How to appeal an insurance company decision
When your insurance company denies a medication or treatment, it is normal to be frustrated and angry. But now is the time for action. You have the right to appeal. How do you get started on the appeals process?
Your health insurer should issue an “explanation of benefits” (EOB). This shows why your medication was denied. It should provide you with your internal appeal rights and information on how to appeal. You can start by following those instructions. Be sure to submit the appeal within the time frame allowed. There should be a phone number to call and a website with the appeals form. Make copies of everything and keep the originals. Submit copies to the insurance.
Your doctor can also file an appeal of the insurance company’s decision on your behalf.
You also have the right to an independent external review and appeal through a third party. Those instructions should also be part of the EOB. Your letter should include the date of the claim, the reasons given for the denial, and why you feel it should be reconsidered. You can also include a letter from your doctor’s office.
Find out what your state’s requirements are for appealing
The first step is to find out what steps you should take based on the state in which you live. Use the search tool at CoverageRights.org to search by state to find out how to proceed based upon your state’s requirements.
How to write a letter of appeal
A letter of appeal is your opportunity to concisely explain why you are appealing the decision to deny your prescription. Your letter should include:
- your name, address and phone number
- insurance ID number
- insurer’s name, address and phone number
- date of the claim and the claim number
- reasons given for the denial
- why you feel the decision should be reconsidered
If you are insured under someone’s plan, include their information as well.
Try to be concise. You can also include a letter from your doctor.
Ask for a case manager
Find out if your insurance company can assign you a case manager. Most insurers have them – even Medicare. Case managers are employed by many health plans. You may think, “Why would someone working for an insurance company want to help?” Case managers are often nurses who work with patients to manage chronic conditions. They find out what treatments have worked in the past. They act as a liaison between you and the PBM. They go to the PBM with information about your condition and your medical needs. And they can advocate on your behalf.
If the medication is helpful, this process can save you and the health insurance company money.
Sometimes your request is sent to a third-party independent administrator to determine if it should be honored. If the administrator approves your request, the insurance company will cover the treatment.
If your medication is still denied, appeal to your state regulator
State insurance regulators ensure that insurance companies are able to pay claims. Contact your state insurance regulator and file a complaint if the health insurance plan denies a prescribed medication.
