As a project director of the Autism Insurance Resource Center of Massachusetts, I work with families who try to get autism therapies covered by insurance. The good news is when a family finds out their insurance covers autism services. The bad news is when this same family gets a denial for the autism services they thought were covered.
What should you do if you receive a denial?
1. Find out exactly what is being denied.
Make sure you know what service is being denied or not approved and why.
2. Get the reason in writing.
If you get your answer over the phone, that’s not good enough.
3. Request your claim file. This is free. These are your records the insurance company keeps about your insurance claims. Your insurance company has 30 days to send you your claim file.
4. Request a copy of your insurance company’s Medical Necessity Guidelines. These are free too.
What is medical necessity and what does it have to do with an appeal?
Most insurance denials are due to “lack of medical necessity”.
It is the standard used to decide whether a treatment or service is appropriate and effective based on the diagnosis. For example, pain medication would be considered an appropriate and effective prescription for a patient with chronic migraines. However, a prescription for an antibiotic would not be considered an appropriate and effective treatment for migraines. The insurance company would not pay for the antibiotic prescription because it is not medically necessary to treat the migraines.
How do I file an appeal?
1. File your appeal in writing. This is absolutely the #1 thing people don’t want to do. No one writes letters anymore. But if you want any chance at winning an appeal, you are going to put your phone down and get on your keyboard.
2. Write down everything and anything that is related to this denial; your insurance number and plan information, the date of service denial, the provider name and the treatment that was denied.
3. Quote directly from the denial letter, state the reason used by the insurer (medical necessity is usually the reason) and explain why it is medically necessary.
4. Be clear and provide references to your medical records.
5. Include your doctor’s letter of support.
6. Write a Personal Statement about your loved one and why they need this treatment.
How long does this take?
The insurance company must issue a decision within 30 days for a service that hasn’t yet been received and 60 days for a service that has already been received, but then denied. If there is a medical emergency, you can ask for a faster review. You will either receive a notice that your appeal has been approved or you will receive a denial of your appeal. Don’t give up. NO may turn in to approved!
More information on appeals can be found through the Office of Patient Protection (OPP). http://www.mass.gov/hpc/opp.
A Guide to Appeals can be obtained for FREE from Health Law Advocates.