Step 3: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.
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 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.
The Sample Appeal Letters included in this guide are designed to be a general guide for your specific letter. Sample Appeal Letter A was written as though the denial was based on a question of medical necessity. Sample Appeal Letter B addresses the issue of a denial based on out of network benefits. Each patient and each denial are unique. It is recommended that you read each letter and then identify other important details that need to be added to your letter. You must also remain factual. It is very important that your denial letter be focused on the intended outcome.
Sample Letter A Sample Letter B
Your Doctor's Appeal Letter
You should also ask your doctor and your specialist to write a letter discussing your specific case and why your treatment is medically necessary. The letter should be addressed to the person at the insurance company that sent you the denial letter, or directly to the medical director at the insurance company. It should include:
- Any information about your illness that your doctor feels is clinically important.
- The prescribed treatment plan.
- Why the treatment is medically necessary.
Ask your doctor and specialist if there are any documents in your medical records that may be helpful in your appeal. For example, it may be helpful to send a pathology result documenting the specific cell type. In the case of certain cancers, the insurance company may need to see what chemotherapy drugs you have already received. In some cases the insurance company may ask to see specific documents from your medical records.
Articles from peer-reviewed clinical journals
Often an insurance company will deny a procedure because they believe there is not enough evidence that the procedure is helpful for a specific disease. If you and your doctor believe this is the basis for your denial, you need to submit documentation that the procedure is effective. This documentation should be in the form of articles that come from the professional journals or "magazines" that doctors use to keep up to date on the latest treatments. These journals have editorial boards of physicians who specialize in specific areas of medicine. That is what makes a journal "peer reviewed". This type of documentation has become very popular with the insurance companies and it is very common for them to request this type of documentation. Your physician and specialist have probably had such a request for information in the past and they can assist you in obtaining these articles.
These four pieces of information should be put together in a "packet" and be submitted to the insurance company by registered mail or some other form that you will be able to track and find out who signed for the information. This will alleviate the excuse that the information was "never received". You should keep a duplicate copy of all the information you are submitting and add it to your file. You may wish to call to confirm receipt of your materials.
After the denial has been received and your appeal has been submitted, the next thing to do is wait for a response. Waiting can be the hardest part. Your plan probably gives a length of time that the insurance company has to respond to your appeal. If it does not, you need to ask the benefits manager or the insurance company when you will be notified of the response. If you are unable to get a response, you may want to consider legal counsel. (see "When to Consult an Attorney")
Sample Appeal Letters
The Physician's Sample Appeal Letter is also a general guide for a specific letter. Most physicians have written appeal letters many times. Some are far removed from the appeal process and are unsure of the specifics of your denial. They may also be unsure of the amount of information necessary. It is important that you communicate the specific reason for the denial to your treating physician and ask that they write their appeal letter with enough information to address the denial specifically.