It’s not unusual for insurers to deny some claims or say they will not cover a test, procedure, or service that doctors order. If this happens, it’s important to have a working relationship with a customer service representative at the insurance company or case manager with whom you can talk about the situation. Before you appeal, you may want to take these steps:
- Ask for a full explanation of why the claim was denied.
- Review your health insurance plan’s benefits.
- Contact your health plan administrator to find out more about the refusal.
- Ask the child’s doctor to write a letter explaining or justifying what has been done or has been requested.
- Talk to your state insurance department or the agency that regulates your insurance company to learn more (see the section “Who regulates insurance plans?”).
You can then re-submit the claim with a copy of the denial letter and your doctor’s explanation, along with any other written information that supports using the test or treatment that has been denied. Sometimes the test or service will only need to be “coded” differently. If questioning or challenging the denial with these methods does not work, you may need to:
- Put off payment until the matter is resolved.
- Re-submit the claim a third time and request a review.
- Ask to speak with a supervisor who may have authority to reverse a decision.
- Request a written response. (Keep the originals of all the letters you get; the team may be able to help you make copies if you need them.)
- Keep a record of dates, names, and conversations you have about the denial.
- Formally appeal the denial in writing, explaining why you think the claim should be paid. Your cancer care team members (doctor, nurse, social worker) may be able to help with this.
- Get help from the consumer services division of your state insurance department or commission. Check the blue pages of your phone book or visit the National Association of Insurance Commissioners (contact information is in the “To learn more” section).
- Do not back down when trying to resolve the matter.
- Consider legal action.
You can learn more about the appeals process from the Kaiser Family Foundation through “A Consumer’s Guide to Handling Disputes with Your Employer or Private Health Plan” which can be found on their Web site at www.kff.org/consumerguide.
The Patient Advocate Foundation also has “Your Guide to the Appeals Process” which can be found on their Web site at www.patientadvocate.org/resources.php?p=13.
A detailed guide from America’s Health Insurance Plans (AHIP) has information about internal and external review of denied claims. It has details on each state’s review process, which can be found at www.healthclaimappeals.org/home.html.
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