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Guide to Appeal - Step4

Guide to Appealing Insurance Denials

Step 4: Write The Appeal Letters

After you have gathered the preliminary information and have a basic understanding of the illness and the insurance policy, you are ready to start the appeal process. Some appeals are handled by the doctor's office or the clinic or the hospital. In this situation, the patient is usually put in contact with a case manager who has experience in the appeals process. In this case, the patient should understand the steps in the process and should 'oversee' what is being done. It is suggested that the patient request copies of all letters and correspondence to and from the insurer. The patient should also be in close contact with the case manager or person handling the appeal for them.

In other situations, the patient and family are informed of the denial and they must handle the appeal on their own. If this is the case, you must manage your appeal. Your appeal should include:
• An appeal letter.
• A letter from your doctor and specialist addressing specifics of your case.
• Any pertinent information from your medical records.
• Any articles from peer-reviewed clinical journals that support your case that illustrate medical efficacy.

Your Appeal Letter
The purpose of the appeal letter is to tell the insurance company that you disagree with their decision and why you believe they should cover the procedure. The letter should be factual and written in a firm but pleasant tone. When writing your appeal letter you should include:

Your identification. This includes your name, policy number, group number, claim number, or other information used to identify your case.

The reason for the denial that they explained in the denial letter.

A brief history of the illness and necessary treatment. Typically this information will be included in the doctor's letter in detail but it can also be helpful to add a shorter and less complicated version in the patient's letter.

The correct information. If you believe the decision was made because of an error, state the correct information, i.e. is the denied procedure different from the requested procedure? Maybe a coding error was made and the insurance company believes you will be receiving a different drug.

Why you believe the decision was wrong. Specific information based on facts to show that the treatment should be provided, i.e. you may have to go out-of-network for a procedure but only because the procedure is medically necessary according to your doctor and there is no in-network provider for the treatment.

What you are asking the insurance company to do. Typically you are asking that the insurer reconsider the denial and approve coverage for the procedure in a timely manner.