Common Traits of Unsuccessful Appeals
Appeals are less likely to go in your favor if they are:
- Hard to read
- Excessively long and include unnecessary details
- Highly emotional and include feelings of frustration, pain, or anger rather than facts
- Incomplete
- Are written with hard-to-read handwriting
- Submitted past the deadline
Why consumers lose appeals
Missing information
- You don't have a letter from your doctor detailing why a procedure is medically necessary.
- Your letter to the health plan doesn't address your specific medical issues or the plan's language.
- You didn't provide documentation of treatments you tried before the treatment your doctor is currently prescribing.
- You didn't provide information about something the health plan considers relevant and wants to investigate.
- You didn't include evidence showing how the medical community considers your treatment as standard practice.
Not in the contract
- You were prescribed or received treatment, or a prescription, that's specifically not covered by the plan.
- You didn't pay your premium on time and your policy was canceled. The health plan will not pay for any medical services after your policy was canceled.
- You disputed the contracted amount the health plan paid to your provider. You cannot ask the plan to pay more or less to a provider than their contract allows.
- You asked about a hypothetical situation. Unless your doctor or other provider is required to get prior authorization for a treatment they determine to be medically necessary, the health plan isn't required to tell you how it would process a claim in advance.
- Things at the discretion of the carrier, such as a request that a prescription be re-categorized so that it costs less.
- Your doctor's billing office makes mistakes. Your health plan can only respond to information provided by your doctor. If your doctor used the wrong CPT code, or didn't get prior authorization, as the plan requires, then your health plan doesn't have to pay your claim. Your provider may be responsible for their mistakes.
Employer and Employee Issues
- Eligibility - For example, when an employer tells the group health plan provider that a worker no longer qualifies for coverage as of a certain date, and the health plan denied any claims that came in for that worker after that effective date.
- Late premium payment - When an employer fails to pay its portion of the premium to the health plan and the health plan cancels coverage for all the employees on the plan.
You cannot fix these last two issues by filing an appeal. You can file a complaint with the U.S. Department of Labor. United States Department of Labor - Employee Benefits Security Administration. Phone: 1-866-444-3272 (toll-free).
