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Guide to Appeal - Step3

 Guide to Appealing Insurance Denials

Step 3: Understand The Illness and The Insurance

You need to understand your condition or your loved one's condition before you can discuss the case with the insurance company. It is very important that you understand exactly what the doctor wants to do and why it is necessary. Read any copies of the letters your doctor may have submitted to the insurance company. The initial letter typically discusses the patient's case in simple medical terms and then explains what the doctor proposes to do. This letter is often referred to as the 'treatment plan' or 'plan of care'. You can also ask your doctor or nurse to explain it further. Often they may have written material that may be helpful, or they may be able to direct you in finding more information.

You need to be familiar with the type of insurance you have. If your insurance is through your employer or your spouse's employer, call the benefits manager and ask him or her to explain the coverage. For example, is the employer self insured and does the employer contract with a third party to administer the plan? Or does the employer contract with an outside company to administer the plan and pay the claims? It makes a difference because you may be able to get your denial overturned by working with the benefits manager or the designated representative of Human Resources. If the company is not self-insured, explaining the problem to the benefits manager, both verbally and in writing, may be very beneficial. The benefits manager can, in some situations, put enough pressure on the insurance company to get the denial overturned. Also, if the employer has had problems with the insurer they may choose not to renew the contract with that insurance company.

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