Whether a patient is enrolled in an insurance program, applying for benefits with a Social Services program or have filed for Social SecurityDisability benefits, there is always a possibility that your application will be denied. If you do not agree with the denial you have received, you will need to appeal the decision. To begin the appeal process, you must first inquire what the process is within that specific program. no one organization, program or policy will require the same procedures. For assitance please refer to the Patient Advocate Foundation publication "Your Guide to the Appeals Process" available online at www.patientadvocate.org or by contacting the Patient Advocate Foundation for individual assistance by a patient liaison representative.
The following information will be necessary to file your appeal, especially to have the denial reversed:
- An appeal letter from the patient stating why you feel the decision is incorrect
- A copy of your denial
- A letter from your attending physician supporting your claim of disability
- Medical documentation to support your diagnosis, course of treatment and disability
Insurance Policy Appeals
All insurance policies are different and unique. It is important to consult the plan summary or policy to determine how to appeal a denied claim and where to file appeals in a timely manner. Most disability policies do not make allowances for late appeals if an individual is incapacitated or is otherwise unable to file an appeal.
Social Security Appeals
If you wish to appeal, you must make your request in writing within 60 days from the date you receive your SSA denial letter. There are four levels of appeal, and they are:
- Hearing by an administrative judge
- review by the Appeals Council
- Federal court review
The reconsideration process occurs when the claimant appeals the initial denial. DDS reviews the previously considered information along with any new information that becomes available. The majority of these appeals are denied unless new materials or medical evidence is documented in the medical records by your treating physician. A written decision is issued with instructions on how to appeal if the claim is denied. Again, an appeal must be filed within 60 days of receipt of teh denial.
If you disagree with the recosideration decision, you may ask for a hearing. The hearing will be conducted by an Administrative Law Judge (ALJ). The ALJ conducts an informal hearing and has a chance to see the claimant in person. The ALJ takes a fresh look at all of the evidence and issues an independent decision based on the merit of the claim. It is helpful for the claimant to have an attorney assisting them when they are at the hearing level. If the ALJ denies, the claimant can start the whole process over by filing a "new" claim for Social Security Disability benefits, which may be filed while an appeal is pending at the Appeals Council.
Appeals Council Review:
Appeals Council Review most often occurs when the claimant appeals an unfavorable decision by the AJL. The Appeals Council may take no action on the case, affirm the ALJ's decision, reverse the ALJ's decision or remand the case back to the ALJ with specific instructions on how to proceed. Currently, there is a 24 month backlog at the Appeals Council.
If you disagree with the Appeal Council's decision or if the Appeals Council decides not to review your case, you may file a lawsuit in a federal district court that can take up two to three years to resolve a case at this level. An appeal may be made all the way to the United States Supreme Court.
Medicare beneficiaries must call the number on their Medicare Summary Notice or 1-800-Medicare. You will need to know the reason the claim is denied to know how to appeal. Patients are encouraged to contact their State Health Insurance Assitance Program or the Patient Advocate Foundation for assistance with Medicare claims denials.
Each state handles appeals for Medicaid benefits differently. If you have denied Medicare coverage or any Social Services benefits, you must contact the department where you initially filed your application. Your caseworker or other staff member can provide you with the contact information for the Appeals Department. Keep in mind that there is a short time limit after your application is denied to file an appeal, you must act quickly. If you do not have the necessary documents available, file your appeal and submit additional documentation at a later date. Patients that need assistance with Medicaid appeals are encouraged to contact the Patient Advocate Foundation for assistance.