Winning your appeal
When you think your health plan should pay for coverage – appeal!
Keep detailed medical records. Most appeals require you to prove something, and it can be a lot easier to do that if you have good records. Document everything.
- Stick to the facts and emphasize objective medical information over discussing your emotions.
- If someone told you they'd get back to you by a certain day and they didn't, call them.
- If something is not clear to you, ask questions until you understand it.
- When you need to send documents to your provider or your health plan:
- Send copies instead of the originals.
- Send documents as certified mail, so you'll know when they are delivered. (Certified mail means someone has to sign for it, and you can see who signed for it and when.)
- Your portion of the cost of medical care is usually negotiable.
- Ask your health care provider to accept the amount your health plan will pay for a procedure as full payment.
- If a health plan won't pay at all, try to agree on a price for you to pay out of pocket.
- Ask your medical provider to change your prescription if it's not covered by your plan.
For a denied claim
- Rule out the possibility of a billing error.
- Call your medical provider's billing office first (document the call on your records log).
- Tell them you received notice of a denied payment in the mail from your health plan.
- Ask why your health plan denied payment for a visit to their office. You will be told it is either a billing error or a claims processing error - both of which should be cleared up by your provider's office. If it's not a billing or processing error, you will need to appeal in order to overturn the denial.
Make sure you have a copy of the current plan summary and exclusions and limitations.
You may need to call your health plan to find out where you can find this information on the plan's website, or ask to have it mailed to you.
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.
Read the denial to learn:
- The specific reason for the denial
- The plan provision that supports the decision
- What the plan needs to reverse its initial ruling
- What your plan's appeals and grievance process is and the deadlines
- Where to send a formal appeal
Consider filing a complaint with the Oregon Insurance Division
Call our consumer hotline at 1-888-877-4894 (toll-free). Discuss your case with an insurance advocate.
Ask for a copy of everything your plan used for the denial.
- Search for any missing information in your file that supports paying the benefit.
- Ensure any clinical research you use is current. Ask your doctor for guidance. Do your own research at www.pubmed.gov.
Stay in contact with your medical provider
If you're appealing the denial, tell your health care provider's billing office staff. Ask them to not send your bill to collections. If they require payment, you can:
- Delay paying it if your provider won't send you to collections;
- Pay it in full; or
- Set up a payment plan. You will be reimbursed if you win your appeal by your health plan.
If you'll need a letter from the medical provider, confirm that he or she will be available to write it (and not away from the office).
Provide your medical provider with a copy of the contract provision the health plan is using
for the denial. You should also give your medical provider any letters or memos the company
sent you for denying the claim. This helps him or her focus their statements on issues related
to your appeal.
- If time allows, ask to proofread the letter your doctor writes on your behalf. Make sure the letter addresses the reasons your health plan is denying the claim. Some letters aren't specific enough or sometimes contain errors. Successful appeals have persuasive letters from doctors.
- Gather all medical records and other supporting documents as early in the process as you can. If your appeal moves on to the external appeal level, you will want to have everything in your possession. That stage of the appeal process has a shorter turnaround time for a decision. You want the IRO (independent review organization) to have everything it needs in the first few days after you file the appeal.
If your health plan requests more time to consider your claim, you don't have to grant it. If your health plan doesn't return a final decision to you in the time allowed, you can move on to the next level of appeal.
For cancelled or rescinded coverage
- Insurance plans must provide you with written notice at least 30 calendar days before they can rescind your health coverage.
Note: A health plan is only allowed to rescind a policy for fraud or intentional misrepresentation (such as knowingly omitting a health condition on an individual application).
Failure to pay premiums:
- Avoid making late premium payments. If you fail to pay your insurance premiums, your health plan might grant you a one-time exception if your payment is late, but this is not required. Be aware the company typically will not allow a second late payment and will cancel your policy.
- Your employer can cancel your COBRA coverage if you don't make your premium payments.
Federal COBRA law doesn't require your employer to notify you that it has canceled your coverage.
However, the federal HIPAA law does require a Certificate of Creditable Coverage be issued
to the subscriber when coverage has ended.
- If you think a former employer canceled your COBRA coverage in error, contact the U.S. Department of Labor (DOL): 1-866-444-3272 (toll-free).
For Individual health plans
- The Standard Health Questionnaire is a questionnaire used by insurance companies to determine
if they will insure adult applicants based on their health. If an insurance company refuses
to sell you a policy because your health history did not meet the company's guidelines:
- You can appeal the application denial.
- Your application denial for an individual health plan is only allowed one level of internal appeal to make its decision.
You can apply for coverage through the Oregon Medical Insurance Pool (OMIP) while your appeal is being reviewed.