It can be quite frustrating working with insurance companies. Knowing how to appeal an insurance claim denial can help you get the medical essentials your child needs. Most insurance companies don’t understand the day-to-day needs of your child the way you do. They work hard to make a profit and if they can save money by denying a claim they will try. Here is what you need to know to file an appeal:
Many of the claims you file with your insurance company will come back denied the first time. It may take a number of attempts before your claim is approved. The most important thing for you to remember is that your insurance company is hoping you will give up. This means the process may be long and may involve jumping through multiple “hoops” before your claim is paid. The best advice we can give you is don’t give up.
Some denials are simply errors. Make sure your claim has the right procedure codes and that no errors have caused the claim to be denied. Many times these denials can be fixed with a phone call or you may need to resubmit the form after the physician changes the code.
In other cases, you need to be aware of your rights. Many essential health benefits must be provided. The Affordable Health Care Act requires individual healthcare plans purchased on the marketplace to include services that in the past were often denied. This includes: Ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services including behavior health treatment, prescription drugs, rehabilitative services and devices, lab services, preventative and wellness services and chronic disease management, and pediatric vision and oral care. This includes all durable medical equipment and devices and all therapies. If you are being denied a claim covered under this list, your insurance carrier is required to pay the claim.
Check your state laws in Kentucky, Indiana or Ohio to determine what services are covered in your state. Advocacy groups and your provider should be able to help you determine what is covered.
Follow the appeal process provided by your insurance company. If you can, obtain a case manager that can help with filing claims for your special needs child. Many times a case manager can be helpful. If your claim is still denied you can still file an appeal. Writing a letter or having a letter from your doctor explaining the situation and why the service or device is medically necessary will help. If your doctor’s letter is short or ambivalent, be sure and attach a concise letter of your own. Be ready to explain how the service or device will save them money in the long run by preventing future hospitalization or other more costly services. Avoid writing a sob story and make sure your professional with proper grammar. If you can include case studies or research explaining the necessity of the item or procedure this can help as well. Include any pertinent medical records. If you are denied just keep appealing. Many times if they know you are not giving up, you will eventually win.
If you lose your appeal you can request a peer-to-peer review or an external review. A peer-to-peer review means that a qualified medical professional such as a physician or pharmacist from the insurance company will interview your child’s physician. Your physician may have to initiate this process but it often works in your favor.
The Affordable Care Act allows anyone who has received a denial to ask for an external review by an independent party. Each state handles this process a little differently. To request an external review you must notify your insurance company in writing 60 days after your first denial. The independent reviewer has 60 days to make a legally binding recommendation. Many times this works in your behalf.
Your employer may be able to sway your insurance company by getting involved. Large companies are an asset to the insurance company and they may pay your claim rather than risk losing the companies business.
If you are still being denied you can call your state insurance boards or call your lawyer. Many times if you are persistent and knowledgeable about your rights, you will be awarded the insurance without a lawsuit.
RSVP Home Care is your local respiratory therapist and durable medical equipment company. We are familiar with insurance claims and will be happy to file your claim and help with any appeals you need to make. If you have questions about your service or equipment, call RSVP Home Care, we will be happy to help you.