Insurance Appeals

business man making a phone call
Your health insurance company might not pay for all prescription drugs or medical services. If it doesn’t, you can appeal. Providers use various names for appeals, such as Request for Reconsideration, Medical Benefit Appeal, Coverage Appeal, Pharmacy Benefit Appeal and Prescription Drug Coverage Appeal.

Why won’t my insurance pay for my drug or service?

Reasons your insurance company won’t pay include:

Your drug isn’t on its list.

Lower-cost drugs are available.

The company hasn’t decided whether to pay for a new drug or treatment.

Your illness doesn’t match what the insurance company has on record.

You’re prescribed a different amount or dosage than what your insurance company allows.

You’re prescribed a certain time to take a drug that your company doesn’t allow.

No matter the reason, you can appeal to your insurance company. To increase your chance of success, follow these do’s and don’ts:

Do:

  • Call the telephone number on the back of your insurance card to find out how to appeal.
  • Appeal as soon as possible.
  • Appeals have a time limit, and they take time to process.
  • Ask your doctor to help you appeal.
  • Follow the steps your insurance company requires.
  • Think about asking someone to help you with the appeal.
  • Make copies of your paperwork before you send your appeal.
  • 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’re appealing. Include copies of your treatment records from your doctor. Include a copy of representative authorizations.
  • Include other items you think support your case.
  • Be as detailed as possible.
  • Call your doctor and pharmacy after a few days to make sure they’re working on your appeal.

Don’t:

  • Wait too long to appeal.
  • All appeals have a time limit.
  • Think you have to do this by yourself. Most doctors will assist you.
  •  Send paperwork that’s not related to your appeal.
  •  Resend paperwork unless your insurance company asks for it again.
  •  Send your original paperwork, unless you’re told to do so.
  • Hesitate to call your insurance company to ask questions.