Insurance Denials & Appeals

PAF works everyday with patients in all different insurance plans who are dealing with the consequences of an insurance denial of something their medical team prescribed. Whether getting to the root of a simple paperwork submission error, or requesting a formulary exemption to access a mediation or expedited appeal for a procedure, the key to a successful decision reversal is understanding the process and staying organized.

Our materials help patients have the skills to not only prevent situations that commonly result in plan denials, but help them with strategies that will increase their chances for binding reversals of a negative decision by their plan.

When your insurance company notifies you that it considers a service, medicine or treatment not part of your benefits, it has denied to pay towards the cost of that item. Denials can be devastating for patients and their providers, frequently causing emotional and financial distress. If the denial is related to care that your doctor or provider believes is vital to your situation, taking time to deal  with the  denial can add significant delay and frustration. 

First, its important to understand that there may be situations where your insurance is not contributing towards the cost of your care, and its not because they have denied to pay for your benefits. Sometimes its simple things that can be fixed by resubmitting the claim, once you locate the error. For example, your doctor has not sent the claim to your insurer and is expecting you to pay 100% of the cost directly or your pharmacy has out of date insurance info and cannot run it through your insurance at the time you are ready for pickup. Sometimes, there is an error in the submission where typos created a mismatch of codes or documentation, or items were missing from the submission kicking back the claim because of processing errors. There are also times where what you are requesting is out of the scope of the benefits of your plan language and was listed among the exclusions for the plan. 

A good analogy of the process rules that come into play might be if you bought a new car and had an issue that you believed was covered under the car's warranty. If you take your vehicle to a service garage that is not authorized to service warranty issues, then your warranty is likely to not cover it, as your warranty is only valid if you take it to a dealer or approved location familiar with that manufacturer. And if you received a scratch and dent on your new car and brought it into the dealer, they likely wouldn't cover it because normal wear and tear is not considered part of your warranty benefits. 

However, once you have gathered information about the situation and verified that the insurer has reviewed your benefits and still denied your claim, there is a process for asking for a reconsideration. This is called an 'appeal' and every plan is now required to give its plan members the opportunity to submit a timely request, and the plan must be transparent about the process and deadlines to do so. 

PAF's materials can help you understand the reasons why your medication or care may be denied, and how to craft an appeal packet that could help.