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Private or Commercial Insurance Appeals

If you have private insurance and your drug or service is denied, you can appeal. An appeal is when you ask your insurance company to change its decision.

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Appealing Insurance Denial

When your drug or service is denied, you usually are sent a “coverage determination document” (also call a “denial letter”). This is the document from your insurance company that says whether they will pay for your drug or service.

Your insurance company will usually list the appeal steps in the coverage determination document or on their website, or you can call them directly. The web address and phone number should be printed on the back of your insurance card.

Your doctor will usually help with an appeal but you can appeal on your own.

You can also give someone permission to appeal for you. This is sometimes called an “authorized representative.”

To begin an appeal, call the phone number on the back of your health insurance ID card. Sometimes it will say “member services” next to the phone number. Ask the person how to appeal. Usually the process will include the following:

  1. Put the appeal in writing. Sometimes there’s a specific form you need to use. Sometimes you can write a letter. The forms and letters need to include:
    • Your name
    • Your address
    • Your phone number
    • Your doctor’s name
    • Your doctor’s address
    • Your doctor’s phone number
    • Your insurance ID number
    • Dates of your claim determination
    • The name of the drug or service you want your insurance to cover
    • Reason(s) why you are appealing the decision.
  2. Fax or mail the information to the insurance company. For the fax number or mailing address, call the phone number on the back of your insurance ID card.
  3. Send additional information.  Some of these items may include:
    • A copy of your insurance card (both sides)
    • The document that said you were denied (called a coverage determination) from your pharmacy or insurance company
    • If you have an appointed representative, a copy of the “appointment of   representative” form
    • Supporting medical documents from your doctor
    • Any other information that may help

How long will the appeal take?

It depends on state law, whether the need is considered urgent or whether your insurance has different appeal levels you need to go through.

Here are the typical timeframes:

  • First appeal request = up to 30 days
  • Second appeal request = up to 60 days
  • Urgent appeal request = up to 3 days

Urgent appeals are when your doctor thinks a delay will put your health at serious risk or cause you serious pain. For an urgent request, call the toll-free number on your insurance card or the number on the coverage determination document.

What if your appeal is denied?

If your appeal is denied, you may be able to request an “external review.” This allows you to have a third party (independent party) review your denied appeal.

Your plan should include information on how to request this review in your coverage determination document. Call your insurance company directly on how to request an external review if the information isn’t in that document.

HHS-administered federal external review

Some insurance plans are part of the “HHS-administered federal external review process.” If your insurance is HHS-administered, you can do one of the following to request an external review process:

Do the following:

  1. Call or email to request an external review request form
    Phone:
    1 (877) 549-8152
    Email: disputedclaim@opm.gov
  2. Complete the form
  3. Send the form to your insurance company
  4. Fax or mail the completed form.  Fax: (202) 606-0036
    Mail:
    External Review Request, P.O. Box 791
    Washington, D.C. 20044

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