You can win an appeal, but it takes some work. First, read the denial letter. Why was coverage denied? what is the appeal process and timeline?
If it’s a billing or claims processing error, call your medical provider’s billing office and ask them to clear things up with the insurer. If a bill becomes due during your appeal process, keep these tips in mind.
If it’s not a billing or claims processing error, you’ll need to appeal to have it overturned. below are some suggestions that might help.
for continuing care in an emergency situation
A health plan must provide continuous coverage pending the outcome of an appeal. may not reduce or suspend the benefits of ongoing treatment without giving you advance notice and an opportunity to review it (rcw 48.43.535(9) (leg.wa.gov).
Note: If you lose your appeal, you may be responsible for those medical costs.
tips for filing your appeal
- Identify your type of insurance coverage and find out if you have a group, individual, or government-sponsored plan, and what law your plan follows.
- for medicare and other plans like tricare, apple health for kids, etc, you will need to follow their appeals processes.
- Find out the deadline for filing an appeal. where do you send it? these are usually in the denial letter. if not, ask your insurer.
- Determine whether you have a non-grandfathered plan or a grandfathered plan and what your appeal options are for your particular plan. If you’re not sure what type of plan you have, call your provider and ask.
- Keep a record of every call, email, and letter. here is a printable example (pdf, 641.36 kb) of a contact record.
- Gather your medical records. if you don’t have them, ask your health care provider for copies. here is a sample letter. (word, 32kb)
- Appeal letters should be accurate, timely, and specific about the result you seek. here is a sample appeal letter (word, 24kb) and a list of common reasons for a denial and sample appeal letters you can use.
- It is helpful to have a letter of support from your medical provider. Give them a copy of the reason for the denial.
- Don’t be afraid to call, especially if someone told you they’d get back to you and didn’t.
- send copies of the documents, not the originals, and send them by certified mail.
what is an independent review organization (iro)?
If your health plan upholds a claim denial after you’ve completed its appeal process, you may request an external review of your appeal through an independent review organization (IRO). this option should be described in the determination letters you receive from your insurer, or you can contact your health plan’s customer service line for more information on requesting an external review. An iro is not affiliated with your insurance company and has no financial interest in the outcome of your case.
the iro can defend or override the position of the insurance company. once an iro reviews an appeal, its decision is binding. All iros in the state of washington must register and be certified by the insurance commissioner’s office.
Our iro search tool allows you to search for iro decisions. You can modify your search based on a number of factors, including cases related to your insurance company, diagnosis, treatment, outcome, or reason for appeal.
you may also want to file a complaint
Whether or not you file an appeal, you may also file a complaint with our office. the appeals and complaints processes are different, and can occur simultaneously without affecting each other. if in doubt, you may want to try both ways to solve your problem.