How to Appeal a Managed Care Denial

In the past decade, managed care and HMO’s have become the norm for most people with commercial insurance. Part of “managing” the care means having strict rules regarding the coverage of your healthcare. Not following your contract may mean that your services will either not be approved for payment or will be denied for payment after the fact. However, a denial from you insurance company is not necessarily the end of the road. You do have appeal and grievance rights.

Instructions

Difficulty: Moderately Challenging

1. Understand that no insurance company can say you CAN’T have the care you want or need. This is a free country, you can do anything you want. But they CAN say they won’t pay for it. For some people, those statements may amount to the same thing, but it is important to understand the difference.
2. Familiarize yourself with your Evidence of Coverage (EOC). This is the long, tedious booklet that you get when you enroll and that, famously, few bother to read. Your health care insurance is a form of contract. The EOC says what will be covered, how it will be covered and what is excluded from coverage by your plan. If you do not know these things, you are at an automatic disadvantage.
3. If you are denied coverage for a service, first ask why. It may be a simple error. However, you may find that a service either is not covered by your contract, the service is limited by your contract or the service does not meet medical necessity. Not meeting medical necessity is not the same as saying you don’t need the requested service. It means the information provided does not meet the criteria the insurance company needs to make a decision.
4. All states have rules and regulations governing health insurance. Contact your state department of health for guidance on how to find the laws that apply in your state.
5. If your service was denied because it is not covered, in most states that is called a grievance. Consult your EOC or call you insurance company to find out what their procedure and time frame is for filing a grievance. Usually, they will require you to write a letter explaining why you think your service should be covered. Sometimes, extenuating circumstances will be taken into consideration and a decision will be overturned. However, a contractually excluded service is almost never subsequently approved.
6. If your service was denied for medical necessity, the laws usually consider this to be more serious and it is more tightly regulated. These cases are usually called appeals. You will need your physician’s support for this, as they will have the medical information necessary to prove your case. The insurance company has to respond quickly, especially if the service has not been rendered yet and/or your doctor asks for an expedited appeal. You need to obtain specifics about why your service was denied and where you did not meet criteria. Sometimes, there is one simple piece of information missing, that, when provided, will have your case overturned. But if you are asking for an exception to the criteria, you will have to make a case for why this is necessary if they are going to cover it.
7. Knowing your rights and having as much documentation as possible is the key to having an adverse decision overturned. In most states, there are several levels of both appeals and grievances, so do not give up with the first “no”. Additionally, you can enlist the assistance of your local legislators and your state Department of Insurance and Department of Health. Part of their job is to intervene for patients who need help with insurance problems.
8. Try to remember that while your health is an urgent, acute matter to you (and rightly so!), health insurance is a business. In spite of popular opinion and news media, while they are definitely concerned with the bottom line, insurance companies are also crucially concerned with customer service. They do want to serve you and there is not a concerted effort to deny necessary treatment. So while appeals and grievances are hard and can be upsetting, try to not take coverage decisions personally.

Tips & Warnings

• Read your Evidence of Coverage before you are sick!!!!! Managed care rules are specific and contractual. If you don’t abide by the contract, saying later “But I didn’t know…” is not going to get you anywhere.
• If you need help with your appeal or grievance, ask a friend or family member. Appeals and grievances can be very emotional. Having someone to support you and help keep track of the details can be important for winning your case.
• This information applies to commercial insurance. Different, Federal rules cover Medicare Managed Care members.