Filing an appeal when you insurance claim has been denied

Before scheduling treatment, check for the following:

Does your plan provide out of network coverage?
Is your provider an HMO (Health Maintenance Organization)?
Is your provider a PPO (Preferred Provider Organization)?

Keep your health insurance card on hand. The card includes identifying information about your policy, including co payments.

Before you get started with the appealing the denial of coverage, check for the following:

Policy exclusions and restrictions

Denials may be made because the policy specifically excludes coverage of a certain treatment, procedure or medicine. Contact your insurer’s case management department to confirm whether specific costs are covered (ideally, this should be done before you are admitted to the hospital for treatment.)

Organize your paperwork

Organize all the information you need from your insurer before you start the appeal process. The "explanation of benefits" should provide a code for the reason your treatment(s) was denied. If you cannot locate the code, ask your insurer to provide it.

Notate the name, date, time, phone number, and extension of each person you talk with, whenever you call your health insurance provider.

Find out exactly to whom the appeal should be addressed and mailed. Keep copies of any written correspondence and send it via registered mail, requesting a return receipt.

Clerical and coding errors

Check to see whether the denial was due to a clerical or coding error. If the denial was due to an error, have your hospital, or physician's billing clerk, correct the error and provide you and the health insurance provider with a corrected copy of the bill, with the correct code.

Reason for denial

Specifically, why was your claimed denied? Follow the guidelines of the “denial letter.” Customize your appeal, specifically for the reason your claim was denied.

Time limitations

Most insurers set aside a time period during which a patient may file for an appeal. Check your policy to determine this time limit, which may be 60, 90 or 180 days. Monitor time limitations so you don't miss the deadline for your appeal.

Emergency Out of Network Care

Coverage/reimbursement of an out-of-network emergency claim, will require proof

1) Of the medical emergency and

2) Confirmation that no in-network provider was readily available, within reasonable proximity of the emergency. Use your emergency medical records, with doctors' notations, to support your claim.

"Experimental" Protocols/Treatment

HIPEC is more commonly denied for payment as “experimental” medical treatment among our fellow patients than any other protocol/treatment. The surgical oncologist who proposes treating you with HIPEC should be your first line of defense for this type of denial. He/she should be prepared to provide you with a letter stating that HIPEC (or any other treatment being denied) is the established protocol/treatment method for your specific diagnosis. His/her letter can be accompanied by medical journal publications by that surgeon or others, as noted in the red Alpha Index section of medical journal articles posted on the Pseudomyxoma Peritonei page at www.pmppals.org

State Appeals Review Boards

If you receive coverage directly from an insurance company, your insurer is regulated by your state’s insurance department. With the exception of Alabama, Mississippi, Nebraska, South Dakota and Wyoming, patients in all other states are allowed to have their appeals considered by an independent external appeals review board.

Generally, the review board consists of physicians and other healthcare providers with expertise in your disease. Contact your state department of insurance for more information.These departments are listed on the Health Insurance link at www.pmppals.org

Additional assistance

Advocacy groups will assist you at no charge. An extensive listing of patient advocacy groups is posted on the Health Insurance page at www.pmppals.org



Articles posted in PMP Pals and on www.pmppals.org are written from the perspective of patients and their families and are not intended to substitute for licensed, professional, legal or medical advice. Patients should seek the counsel of their licensed healthcare providers. Copyright © 2011 by Gabriella Graham/PMP Pals’ Network/All rights reserved. Visit us on the web at www.pmppals.org