How to Appeal a Denied Medical Referral

Appealing a Denied Medical Referral

It can be frustrating when one wants or needs to visit a doctor or a related health care provider, such as a physical therapist or occupational therapist, and the medical referral is denied by one's insurance provider. In such an instance, one may seek to appeal such a determination by the insurer. The appeal of the denied medical referral takes some preparation and a review of insurance plan documents, but it may result in obtaining the desired medical referral.

Things You'll Need

• Your medical insurance plan documents
• A medical dictionary
• A legal dictionary
• The names and addresses of the medical providers you seek to visit

Instructions

1. Obtain a copy of your insurance plan description documents. If you have your medical insurance through your job, a copy of this document should have been provided to you when you accepted your job. If your spouse's job provides medical insurance for you, ask your spouse for the information. If you purchase your own private medical insurance, these documents should have been provided upon purchasing the plan. If you do not have the documents in your possession, ask your employer (or the provider if you bought your own plan) to provide you with a copy.

2. Review the plan documents carefully. Look for a section that states "Appeals" and "How to File an Appeal." In addition, look for the timing of when to file the appeal. You want to look for the way to go about filing the appeal; many insurance companies provide the exact manner in which the appeal must be filed and a failure to file the appeal in the precise way will automatically result in a loss of the appeal. Once located, highlight this section.

3. Draft a letter of appeal. In your letter of appeal, be sure to include the reason why you are appealing the denied medical referral. Clearly cite any medical reasons for the medical referral and include medical documentation, such as test results or a letter from your doctor indicating the reasons why you need to obtain the medical referral.

4. Follow the "Appeal" process exactly as described in the plan description and include your letter of appeal. Mail the appeal to the address provided in the plan description by certified mail with a return receipt requested so you have proof that the appeal was received by the insurance company. If you do not get a response within a reasonable timel, be sure to follow up with the insurance company to know the status of the appeal.

Tips & Warnings

• If there is one available, always include a reference or case number in your communication with the insurance company.

• This is general information and not legal advice. Always consult with an attorney in legal matters.

• Consider retaining an attorney when your rights are violated. Consider hiring an attorney to handle the appeal of a denied medical referral.

References

• Disability Rights Network of Pennsylvania How to Appeal a Medical Assistance Denial of Assistive Technology