Denials / Appeals: What to Do When Your Insurance Company Denies You Coverage – JDRF

How to appeal insurance decision

Video How to appeal insurance decision

“Before my son was diagnosed with dt1, I had never been denied treatment. I was shocked and really upset when I got the notice. i talked to another mom who has a child with t1d and she encouraged me to file an appeal. I had never heard of that! The first time, she took several calls to my son’s insurer and doctor, but when I finally appealed, they accepted it! now if I see denial happening I know what to do and it’s not that scary.”—t1d’s caregiver, tn

in this section we will discuss

  • what is a health insurance denial?
  • what is an appeal?
  • Steps to Consider When Filing an Insurance Appeal
  • balance billing for out-of-network care
  • helpful resources
  • what is a health insurance denial?

    A denial is when your health insurance company notifies you that it will not cover the cost of your medication or treatment. It can be frustrating and sometimes scary if you’re not able to fill a prescription, continue a treatment, or face paying the full cost of your treatment. The good news is, you have the right to appeal the decision. And, while it can be time-consuming to deal with, many health insurance denials may be resolved through the insurance appeals process. In this section, we’ll review why you may receive a denial, some steps you can take to dispute the decision by filing an appeal and some helpful tips to be aware of as you’re navigating the appeals process.

    To get started, it’s best to understand why you may have received a denial in the first place. This explanation usually comes in a document called an Explanation of Benefits (EOB) from your insurer. here are some common reasons and tips on what to do in each case. The next section provides more information about the appeals process and some tips on how to help increase the chance that your treatment will be approved.

    What Is an Appeal?

    When you make an appeal, you are asking your insurance company to reconsider its decision to deny coverage of a drug, treatment, or service for your type 1 diabetes condition. The possibility of your appeal being approved is the reason more convincing to continue: More than 50 percent of coverage or reimbursement denial appeals are ultimately successful.1 This percentage could be even higher if you have an employer plan that is self-insured . Despite the promising success rate, appealing an insurance denial can be a daunting task. To help you get started, we’ve outlined the steps to consider when filing an appeal, key tips to remember, resources to help support this process, and a sample letter.

    “I had been using my cgm for a few years when my employer changed insurance companies. my first supply order was denied. I didn’t file a formal appeal, but I arranged a peer-to-peer call between a plan medical director and my endocrinologist. after that call my cgm supplies have been covered when i need them.” —art, 57, connecticut

    the appeals process has some elements common to all health plans; these elements are described below. That said, it’s important to check your plan’s specific process and required information. these can be found in your policy documents or on your plan’s website. If you have a plan provided by your employer, you can check with your human resources department or the member handbook provided to you when you enrolled. if you have medicare coverage, check your medicare & your manual for the specific process.

    If your health insurance has denied your claim, you can start the appeal process, which has three different levels:

    • First Level Appeal – This is the first step in the process. you or your doctor contact your insurance company and ask them to reconsider the denial. Your doctor can also ask to speak with the insurance plan’s medical reviewer as part of an “insurance peer review” to challenge the decision. The purpose of the first appeal is to prove that your service meets insurance guidelines and was wrongly denied.
    • Second Level Appeal: In this step of the process, the appeal is typically reviewed by a medical director from your insurance company who was not involved in deciding the claim. The purpose of this appeal is to prove that the request should be accepted within the coverage guidelines.
    • Independent External Review: In an external review, an independent reviewer from the insurance company and a doctor with the same specialty as your doctor review your appeal to determine whether to approve or deny coverage. people often turn to external review if an internal appeal is not possible or successful.
    • In the next section you will find some common reasons why you may have been denied and what you can do.

      Challenging a denial of coverage by a health insurance plan is a legal right guaranteed to all insured persons. Each plan, including private policies, employer-sponsored health plans, Medicare, Medicare drug plans, and Medicaid, must provide a process for reconsideration of any adverse coverage determination by the plan.

      1 The National Multiple Sclerosis Society Toolkit for Physicians: Second Edition, 2009.

      Check your plan’s directory of participating doctors. If the doctor you saw was out of network, you could be responsible for some or all of the costs, depending on whether or not you had the option to see this doctor. if the doctor is listed as in-network for your plan, file an appeal with a referral to the physician directory. If you’ve been to the emergency room or had a procedure and a specific provider you didn’t choose is billing as out-of-network, be sure to let your insurance company know you’re receiving these bills. they can help you determine if you will have to pay them.

      Check with your doctor’s office to confirm they have been submitted to the correct insurance company for you (sometimes they have outdated insurance information) and may need to be resubmitted.

      Call your insurance company’s member services number to find out if or why your coverage has lapsed, and provide the information needed to confirm coverage if you’re still enrolled and paying premiums.

      Steps to consider when filing an insurance appeal:

      know your data

      • Be prepared to share your insurance information (your plan number, member number, and date of birth) in every interaction. also have ready the claim number indicated on the document, the date and the doctor who provided the services. insurance companies need to locate the claim in question before reviewing it, so you’ll likely repeat this information several times.
      • Determine why you received an insurance denial claim by reviewing your insurance plan’s eob or calling a member services representative. Be sure to have the name of the service or medication denied, along with the reason cited, for all of your written and oral follow-ups.

        You may want to sign up for an online account with your insurance company, which will allow you to view documents like eobs more quickly than getting them in the mail.

      • Keep a record of the date, time, representative name, and outcome of your conversation in case you need to follow up later.
      • Please refer to your plan documents or your plan’s website to understand the insurance appeal process. some plans require more than one internal review before you can request an external review.
      • take time into account

        • check with your plan to confirm the time limits for filing an appeal after receiving a denial; Be sure to submit your appeal within these time limits, as wasting time is an immediate reason to deny your appeal.
        • if the case is urgent, your insurance company should expedite this process; Your doctor will need to be part of the appeal process to confirm the medical necessity and urgency of your request.
        • recognize that the appeal may not work quickly and may need to be filed multiple times. Often times, patients who are initially denied eventually get approved for the coverage they need.
        • Be organized

          • Be prepared to share your insurance information (your plan number, member number, and date of birth) in every interaction. also, have ready the claim number indicated in the document, the date and the doctor who provided the services. insurance companies need to locate the claim in question before reviewing it.
          • Be sure to keep copies of everything you send to your insurance company (including the final appeal letter) and to coordinate your appeal efforts with your doctor.
          • work together

            • talk to your doctor and his office staff for their help and support; be sure to coordinate who will write the letter and send it to your insurance company.
            • work with your doctor’s office to write your appeal:
              • decide who will take the lead, you or your doctor.
              • include a supporting letter from your doctor, including:
                • the medical reasons why the service should be approved
                • notes on how you have responded to treatment or medication
                • results of any relevant tests and laboratories related to the requested service
                • peer-reviewed articles or clinical guidelines supporting recommended treatment
                • verify your documentation before submitting to ensure you are not submitting duplicate or confusing information to your insurer.
                • request a “peer” review at the first level appeal, this is usually a phone conversation between your doctor and a doctor from your insurance company to discuss why the drug or treatment is necessary and must be covered.
                • Remember that persistence is important, and many times patients who are initially denied eventually get approved for the coverage they need.
                • balance billing for out-of-network care

                  As of January 1, 2022, a new federal law will take effect that prohibits balance billing. This new rule will prevent health care consumers from being overcharged when they receive unexpected care from an out-of-network provider. this will apply to people with individual and work-based health plans who receive emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. network.

                  In an emergency, a person may go or be taken to an out-of-network hospital for care. the hospital may be out of network or even if the hospital is in network, the providers who work at the hospital may be out of network. Also, even if a person chooses an in-network facility for an elective procedure, a provider such as an anesthesiologist may be out-of-network. In many states, out-of-network providers were allowed to bill the difference between the rates paid by the insurance company and the full list price. this will now be prohibited. cost sharing will be limited to in-network amounts and will count toward deductibles and out-of-pocket maximums. Health plans cannot retroactively deny coverage for emergency care, so costs cannot be applied after the care is provided. The facility must also post information on how to contact state or federal authorities if you believe this law has been violated.

                  In addition, in limited cases, a provider or facility may notify a person of possible out-of-network care and obtain the person’s consent for that out-of-network care. this may incur additional costs, but this option can only be used in limited circumstances.

                  key details:

                  No one can be billed for an out-of-network health care service when you go to the emergency room or receive care from an out-of-network provider while at an in-network facility (i.e., an in-network hospital).

                  emergency services must be covered without prior authorization and regardless of whether a provider or facility is in-network

                  Cost sharing must be limited to in-network levels, must count toward deductibles and out-of-pocket maximums

                  The rule applies to people with work-based health insurance (including erisa plans and federal, state, and local government health plans) or individual. Does not apply to people with coverage through programs such as Medicare, Medicaid, Indian Health Services, Veterans Health Care, or Tricare, because they are already prevented from balance billing.

                  If you get a surprise bill for medical care you thought was covered, go to or call the No Surprises Law Enforcement Help Desk at 1-800-985- 3059, open 8 a.m. to 5 p.m. m. to 8 p.m. ET, 7 days a week, and you can get help determining if your provider and insurer are following the rules of this new law.

                  useful resources:

                  Consumer Assistance Programs – Many states have consumer assistance programs to help you with your appeal. You can usually find this contact information on your insurance company documents or by contacting your state insurance department. If you have coverage through your employer, your human resources department may also be able to help. see section 7 for information on working with your employer and how you can sometimes be an advocate on their behalf.

                  health care advocate – You may also find it helpful to work with your state’s health care advocate, a person who can help you through the process and help you resolve a claim problem on your behalf.

                  If you have exhausted all levels of appeal and still receive a denial, your other alternative is to find help paying out-of-pocket for the drug or treatment you received. Find more information in the “Help with your health care costs” section.

                  jdrf maintains a forum where insurance topics can be discussed. if you have questions for the community, you can post them here!

                  Is this resource useful? did we miss something? let us know!

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