The Appeals Process

What to do if Your Health Insurer Refuses to Pay for Treatment

FIRST STEPS

Obtaining and Reading Your Plan Documents

When you are seeking to have an insurer cover your medical treatment, the first thing to do is look at your insurance plan documents and carefully read its terms.  This document will specify what services are and are not covered.  If you do not have a copy of your plan documents, you can contact the insurer and request a copy. If you receive insurance through your employer, you can often request a copy from your Human Resources Department.

Medical Necessity

Before you can get any services covered you must have a medical provider who is willing to provide the treatment and can verify that the treatment is “medically necessary.”  Insurance companies will only pay for treatment that is “medically necessary” which means treatment that is consistent with the generally accepted medical practice.  In determining medical necessity the insurer will consider whether the treatment requested is the most appropriate given the condition, whether the treatment is known to be effective, and whether there is a less expensive treatment option that is medically proven to work just as effectively.   Many disagreements with insurance companies involve disputes over medical necessity.

For each type of illness or condition, the insurance company sets standards that explain the medical necessity criteria. You or your provider can request a copy of the medical necessity standards for your particular medical condition from the insurance company. It is often helpful for your provider to review the insurance company’s specific criteria before he or she tries to get a service covered or assist you in appealing a denial of coverage.

If your provider does not agree with you that the treatment you feel you need is medically necessary or appropriate, the provider has a right not to treat you. In this case, you will need to find another provider who is willing to treat you and willing to submit the necessary request for those services to your insurance company.

Communicating With Your Insurer

The next step is to make sure your provider has spoken to the appropriate person at the insurance company (this person is often called a utilization reviewer) to request the services are covered.  If you think the services may not be covered, and your condition does not require immediate or emergency care, it is always best to request prior approval from the insurance company.  If the services are denied, you need to make sure you have a written denial notice. You can not begin the appeals process without this written denial; verbal conversations are not sufficient.  Even if you or your provider have a feeling the treatment will not be covered, if your provider believes the treatment is medically necessary,  have your provider submit a prior authorization form; if you are then denied the treatment, you will be provided with information regarding how to appeal this decision.

MASSHEALTH DENIALS

Massachusetts’ Medicaid program is called MassHealth.  If MassHealth denies coverage for a service or treatment, you will get a denial notice explaining why they won’t pay for the services requested. The notice should give you enough detail so you know why the insurer thinks the services are not medically necessary.
    
Once you have any denial notice, file an appeal immediately.  At the bottom of the denial notice, there will be information about your appeal rights.  If it is for the continuation of services you already are receiving and you file the appeal within 10 days of receiving the denial notice, you can ask for the services to continue until the appeal is decided.  You should appeal in writing and save a copy for your records. You should ask your provider to write a letter supporting your appeal and explaining clearly, and in as much detail as possible, why you require the requested services or treatment. The provider should include copies of any medical records or diagnostic test which support the care requested.

PRIVATE HEALTH INSURANCE DENIALS

When your insurer denies a service, you will get a denial notice telling you why the insurance company won’t cover the requested services. The notice should give you enough detail to understand why the insurer has decided the services are not medically necessary. The notice should explain why the medical evidence your provider has submitted fails to meet the insurer’s medical review criteria. The letter should refer to the clinical practice guidelines and review criteria used to reach this decision.  If the notice does not give you enough information, call the insurer and ask for clarification or explanations.  Take careful notes and also ask the insurer to send any additional explanations in writing.

Internal Appeals

At the bottom of the denial notice, there will be information about your appeal rights.  You should file a written appeal immediately and save a copy for your records. You should ask your provider to write a letter supporting your appeal and explaining clearly, and in as much detail as possible, why you require the requested services or treatment. The provider should include copies of any medical records or diagnostic test which support the care requested.  Insurance plans often publish information on how to file appeals and you can often find this information on their websites.

External Appeals

Once you have exhausted the internal appeals process, you may have further external appeal options available to you based on your type of plan. In general, if your insurance is through your employer and the insurance is actually from an insurance company as opposed to your employer providing the insurance and the insurance company merely administering your employer’s self-insured plan, you will likely have appeal options. If you did not purchase the insurance through your employer, but rather bought it directly from an insurance company, you will have appeal options. If, on the other hand, your insurance is actually provided by your employer, even though the plan is administered by an insurance company, your appeal options will be very limited.

The letter from the insurance company denying your internal appeal may provide information about the Office of Patient Protection (OPP). OPP, part of the Massachusetts Department of Public Health, offers an external review process through which individuals can have an independent reviewer decide whether the insurance company’s medical necessity determination was correct. If the OPP reviewer disagrees with your plan’s decision, he can overturn the denial and order the insurer to coverage the services.  In order to be eligible for external review, the service or treatment being requested must be a covered benefit in the particular health plan contract. You have 45 days from the date you receive final adverse determination (you lose your internal appeal) to file for external review.  When you appeal to OPP, make sure to submit as much documentation as possible to support your request, including medical records and letters from your providers clearly explaining why the treatment is medically necessary and why there are no appropriate alternatives.  External review agencies have 60 business days to make a determination.  For more information on this process contact OPP at 1-800-436-7757 or http://www.state.ma.us/dph/opp.

Mental Health Services

Many private health insurance companies may contract with separate behavioral health management companies to manage their member’s mental health care services. If you are appealing a denial of mental health care services or treatment, you may first need to file an internal appeal with the behavioral health management company. If that company denies your appeal, you may then have to file a further appeal with your main insurance company. Details on this process should be provided in your plan documents.

Sources: Masslegalhelp.org, information written by Mental Health Legal Advisors Committee.

Note: The information is on this website is not legal advice. The contents are intended for general information purposes only. The information on this website may not contain complete statements of the law and we do not guarantee its accuracy as laws change frequently.  Viewing this website or sending an email message through this website does not create an attorney-client relationship. Legal advice depends on the specific facts and circumstances of each individual’s situation. Those seeking specific legal advice should contact Health Law Advocates at 617-338-5241.