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Insurance Appeals Guide

Not all drugs or medical services will be paid for by your health insurance. Sometimes your insurance company will say no or will only pay a small amount. If this happens, you can appeal.

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What is an Insurance Appeal?

An insurance appeal may be called different things by different providers such as Request for Reconsideration, Medical Benefit Appeal, Coverage Appeal, Pharmacy Benefit Appeal, or Prescription Drug Coverage Appeal.

An appeal is when you ask your insurance company to change its decision about covering the cost of a prescription or medical service. Every insurance type and plan has a different appeal process. Although there is no uniform way to do an appeal, the following information explains some things about the various private and government insurance types.

Why won’t my insurance pay?

Sometimes your insurance company will not pay for your drugs or medical services. This happens for different reasons, such as:

  • The insurance company has a select list of drugs it will pay for but your drug isn’t on the list.
  • There are lower-cost drugs available.
  • The drug or treatment is so new, the insurance company hasn’t decided if it wants to pay for it yet until the company learns more about it.
  • Your illness doesn’t match the illness the insurance company has on record for that drug to treat.
  • Your prescription instructs you to take a different amount or dosage than what is allowed by your insurance company.
  • Your prescription instructs you to take the drug for a different amount of time than what is allowed by your insurance company.

No matter the reason, all insurance companies allow you to ask that they change their decision. This request is known as an appeal.

Types of Health Insurance

  • Private or commercial health insurance. Many different companies run these programs. Some examples include Aetna, Blue Cross/Blue Shield and United Healthcare.
  • Government health insurance. Such as Medicaid, Medicare, Veterans (VA) Health, Benefits or TRICARE

How do you file an appeal?

Every insurance type and every insurance company has a different set of steps that you and your doctor will need to do to appeal. Although the steps may be different, some parts of the process are the same from company to company.

Some common steps and items needed for appeals across most insurance types include:

Insurance or Member ID Cards

All insurance types give you an insurance card. This card contains very important information, including:

  • The name of your insurance
  • Your identification number
  • The phone numbers to call for appeals and other information

Calls the Insurance Company

Most appeals start with a phone call to the insurance company. The number is usually on the back of the insurance card. This call is to find out how to appeal and where to send the appeal.

Follow Your Insurance Company’s Process

Each insurance company has a process to follow, depending on the insurance type. Follow the steps outlined by your insurance company. Some common steps are:

1. Send the appeal in writing. Sometimes there’s a specific form you need to use. Sometimes you can send a letter. The forms and letters usually need to include some or all of the following:

  • Your name
  • Your address
  • Your phone number
  • Your doctor’s name
  • Your doctor’s address
  • Your doctor’s phone number
  • Your insurance 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.  Send additional information with the written appeal.  information 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

3.  All information needs to be faxed or mailed.  Depending on the process at your insurance company.

Additional Tips

  • Always write your insurance number on anything you send to the insurance company.
  • Make copies of what you send.

Insurance Appeals Do’s and Don’ts

It is your right to file an appeal for payment with your insurance company if you feel that a drug or service should have been covered but wasn’t. Follow this list of “Do’s and Don’ts” to increase your likelihood of success in your appeal.

DO:

  • Use the phone numbers on the back of your insurance card to call and find out how to make your appeal.
  • Make your appeal as soon as you decide to appeal. Appeals have a time limit, no matter the insurance type, and they take time. The sooner you get started the better.
  • Ask your doctor for help with an appeal.
  • Follow the steps your insurance plan tells you to do.
  • Think about asking someone you know to help you with the appeal.
  • Make copies of your paperwork before you send it to anyone.
  • Include your name, address and phone number in your appeal.
  • Include your doctor’s name, address and phone number in your appeal.
  • Include your insurance ID number and any other claim number on everything you send with your appeal.
  • Include the name of the drug or service you are appealing.
  • Include any copies you can get of your treatment records from your doctor.
  • Include a copy of any representative authorizations.
  • Include any other items you think support your case.
  • Be as detailed as possible about what you are appealing.
  • Call your doctor and pharmacy after a few days to make sure they are working on your appeal.

DON’T:

  • Don’t wait too long to appeal. Appeals all have a time limit, no matter the insurance type.
  • Don’t think you have to do this by yourself. Most doctors’ offices will help or you can look into getting someone to help.
  • Don’t send paperwork if it doesn’t have anything to do with your appeal.
  • Don’t send paperwork you already sent unless the insurance company asks for it again.
  • Don’t send your original paperwork. Only send copies (unless you are told to send the originals).
  • Don’t hesitate to call your insurance with any questions. The phone number is on the back of your insurance card.

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