Denials and appeals
What to do when your insurance company denies you coverage.
Before my son was diagnosed with T1D, I had never been denied for a treatment. I talked with another mom who has a child with T1D, and she encouraged me to file an appeal. Now if I see a denial come through, I know what I need to do, and it’s not as scary.”
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 begin, it is best to understand why you may have received a denial in the first place. This explanation typically comes in a document called an Explanation of Benefits (EOB) from your insurer. Here are some common reasons and tips for what to do in each case. The section below provides more information on the appeals process and some pointers for how to help increase the likelihood of getting your treatment approved.
What is an appeal?
When you file an appeal, you are asking your insurance company to reconsider its decision to deny covering a medication, treatment or service for your type 1 diabetes condition. The potential of having your appeal approved is the most compelling reason for pursuing it—more than 50 percent of appeals of denials for coverage or reimbursement 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 have outlined steps to consider when filing an appeal, key tips to remember, resources to help support this process, and a sample letter.
Appeal Process
The appeals process has some common elements across all health plans; these elements are outlined below. That said, it is 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 you were provided when you enrolled. If you have Medicare coverage, check your Medicare & You handbook for the specific process.
If your health insurance denied your claim, you can start the appeals process, which has three distinct levels:
- First-Level Appeal—This is the first step in the process. You or your doctor contact your insurance company and request that they reconsider the denial. Your doctor may also request to speak with the medical reviewer of the insurance plan as part of a “peer-to-peer insurance review” in order to challenge the decision. The purpose of the first appeal is to prove that your service meets the insurance guidelines and that it was incorrectly rejected.
- Second-Level Appeal—In this step of the process, the appeal is typically reviewed by a medical director at your insurance company who was not involved in the claim decision. The goal 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 with the insurance company and a doctor with the same specialty as your doctor assess your appeal to determine if they will approve or deny coverage. People often turn to an external review if an internal appeal is not possible or is unsuccessful.
In the next section you’ll find some common reasons you may have been denied and what you can do.
Challenging a coverage denial by a health insurance plan is a legal right guaranteed to all insured individuals. Every plan—including private policies, employer-sponsored health plans, Medicare, Medicare medication plans and Medicaid—must provide a process for reconsideration of any adverse determination of coverage by the plan.
The National MS Society Toolkit for Clinicians: Second Edition, 2009.
| COMMON REASONS FOR AN INSURANCE DENIAL | WHAT TO DO ABOUT IT? |
|---|---|
| YOUR CURRENT CARE IS NOT DEEMED MEDICALLY NECESSARY OR APPROPRIATE. | Work with your doctor through the plan’s appeals process to provide proof that your treatment is medically necessary. |
| THE CARE IS VIEWED AS EXPERIMENTAL OR INVESTIGATIONAL. | Work with your doctor to illustrate that your current treatment is improving your T1D through data such as A1C levels and/or is recommended by clinical guidelines. |
| CLERICAL ERRORS LIKE TYPOS, MISSPELLINGS IN THE ORIGINAL PAPERWORK OR DATA ENTRY ERRORS ON THE CLAIM OR INSURANCE POLICY NUMBER. | You won’t immediately know if this has happened, but it may be an important question to ask when you work to understand why your claim was denied. Work with a member services representative at your insurance company to confirm that no mistakes were made. |
| THE DOCTOR YOU SAW WAS OUT-OF-NETWORK. | Check your plan’s participating doctor directory. 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 a choice to see this doctor. If the doctor is included as in-network for your plan, file an appeal with a reference to the doctor directory. If you were in the emergency room or having a procedure and a specific provider that you didn’t choose is billing as out-of-network, be sure to inform your insurance company that you are getting these bills. They can help you determine if you will need to pay them. |
| THE MEDICATION OR TREATMENT REQUIRED (BUT DID NOT HAVE) A REFERRAL OR PRIOR AUTHORIZATION FROM YOUR DOCTOR. | Confirm if you needed a referral or prior authorization by checking your plan documents or by calling a member services representative at your insurance company. Work with your doctor to submit the appropriate referral or prior authorization. |
| YOUR COVERAGE HAS LAPSED, OR YOU ARE NO LONGER ENROLLED WITH THE INSURANCE COMPANY THROUGH WHICH THE CLAIM WAS SUBMITTED. | Check with your doctor’s office to confirm they have submitted to the correct insurance company for you (sometimes they have outdated insurance information) and may need to resubmit. Call the member services number at your insurance company to find out if or why your coverage has lapsed, and provide any necessary information to confirm coverage if you are still enrolled and paying premiums. |
My employer changed insurance companies and my first order of CGM supplies was denied. I didn’t file an appeal but arranged a ‘peer-to-peer’ call between a plan medical director and my doctor. After that call, my CGM supplies have been covered when I need them.”
Steps to consider when filing an insurance appeal
Know your details
- Be ready to share your insurance information—your plan number, member number and date of birth—in each 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 it’s likely that you will repeat this information multiple times.
- Determine why you received an insurance denial claim by reviewing your insurance plan’s EOB or calling a member services representative. Make sure you have the name of the service or medication denied, along with the reason cited, for all of your written and spoken follow-ups.
- You may wish to sign up for an online account with your insurance company, which can enable you to see documents like EOBs more quickly than obtaining them by mail.
- Keep track of the date, the time, the name of the representative and the outcome of your conversation should you need to follow up later.
- Consult your plan documents or your plan’s website to understand the insurance appeals process. Some plans require more than one internal review before you can request an external review.
Be mindful of timing
- Check with your plan to confirm the time limits for filing an appeal after you receive a denial; make sure to submit your appeal within these limits, as missing the timing is immediate grounds for denying your appeal.
- If the case is urgent, your insurance company should speed up this process; your doctor will need to be part of the appeals process to confirm the medical necessity and urgency of your request.
- Recognize that the appeal may not work quickly, and that it may require filing multiple times. Often, patients who are initially denied eventually get approved for the coverage they need.
Be organized
- Be ready to share your insurance information—your plan number, member number and date of birth—in each 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.
- Make 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
- Speak with your doctor and their office staff to request their help and support with your Make sure to coordinate who will write the letter and submit it to your insurance company.
- Partner with your doctor’s office to write your appeal:
- Determine who will take the lead, you or your doctor.
- Include a letter of support from your doctor, including:
- The medical reasons the service should be approved
- Notes on how you’ve responded to the treatment or medication
- Results of any relevant tests and labs related to the requested service
- Peer reviewed articles or clinical guidelines that support the recommended treatment
- Check your paperwork before you send to ensure you aren’t sending duplicate or confusing information to your insurer.
- Ask for “peer-to-peer” evaluation in the first-level appeal This is typically a phone conversation between your doctor and a doctor at your insurance company to discuss why the medication or treatment is necessary and should be covered.
- Remember that persistence is important, and many times patients who are initially denied eventually get approved for the coverage they need.
External review of denials
According to the Center for Consumer Information and Insurance Oversight (CCIIO) current law provides consumers with the right to appeal health plan decisions to deny payment of claims to an outside, independent review organization called an External Review Organization (ERO). This right exists for everyone enrolled in a commercial health plan regardless of the state of residence. The right to an external review is guaranteed under provisions of the Affordable Care Act. Every state and every insurance company offering coverage must provide access to an independent external review process. The decision rendered by the ERO is legally binding. The external review process can be used as a final step to appeal a health plan decision. The external review commonly occurs after an internal review is completed. Some states allow for the external review to occur in tandem with the internal review. Typically, external reviews are completed within 45 days of request and within 72 hours for expedited requests.
Balance billing for out-of-network care
Starting on January 1, 2022, a new federal law banning balance billing will go into effect. This new rule will prevent health care consumers from being excessively charged when unexpectedly receiving care from an out-of-network provider. This will apply to people with job-based and individual health plans who get emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.
In an emergency, a person may go to 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, providers working at the hospital may be out-of-network. Additionally, 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 previously allowed to bill for the difference between the rates they were 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 care is provided. The facility must also post information about how to contact state or federal authorities if you think this law has been violated.
Additionally, in limited cases, a provider or facility can provide notice to a person regarding potential out-of-network care and obtain the individual’s consent for that out-of-network care. This may result in additional costs but this option may only be used in limited circumstances.
Key details:
- No one can be billed for an out-of-network health care service when going to the emergency room or getting care from an out-of-network provider while in 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 job-based (including ERISA plans, and local, state and federal government health plans) or individual health insurance. It 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 being balance billed.
- If you receive a surprise bill for medical care that you thought would be covered, go to https://www.cms.gov/nosurprises/consumers or call the No Surprises Act Help Desk at 1-800-985-3059, open from 8am-8pm EST, 7 days per week, and you can get assistance determining if your provider and insurer are following the rules of this new law.
Helpful resources
Consumer assistance programs
Many states have consumer assistance programs to help you with your appeal. You can usually find this contact information on the documents from your insurance company, or by contacting your state insurance department. If you have coverage through your employer, your human resources department may also be of assistance. See Section 7 for information on working with your employer and how it can sometimes be an advocate on your behalf.
Healthcare Ombudsman
You may also find it helpful to work with your state’s healthcare ombudsman, an individual who can assist you in the process and help resolve a claim issue on your behalf.
Help with costs
If you’ve exhausted all the levels of the appeal and are still met with a denial, the other alternative is to find help covering your out-of-pocket costs for the medication or treatment you received. Find more information in the “Help with Your Healthcare Costs” section.
