Prepare to File an Appeal
First, figure out what kind of plan you have.
When you file an appeal, the steps you take will depend on what kind of insurance plan you have. Some types of plans are:
Individual plan: This plan can be bought through an insurance company or a state's health insurance exchange.
Plan that is paid for by the employer: The employer buys an insurance plan from an insurance company, and the insurance company pays for medical costs.
In a self-funded plan, your health care costs are paid for directly by your employer. Most of the time, an insurance company is hired by the employer to run the plan.
Medicare: Call aJustSolutions (855-657-3311) for free help with an appeal, or talk to the provider of your State Health Insurance Program.
Medicaid: Contact the Medicaid office in your state.
Need help figuring out what kind of health plan you have? Triage Cancer provides a questionnaire to help you identify your plan. Or, you can call the insurance department of your state to find out what kind of plan you have.
Step 2: Figure out why you were turned down.
Here are some reasons why your claim may have been turned down. There may be more reasons that aren't on this list.
Administration: Codes were wrong
Experimental or investigational: Off-label drug use
Your health plan doesn't cover the service or benefit
Not one of the benefits: Surgery for looks
Step 3: Get proof that the treatment or service is needed for medical reasons.
Work with your medical team to show why the treatment or service is important. This can be a letter from your doctor, a copy of your medical records, or a piece of medical literature that says a certain treatment works.
Tip 1: Use a spreadsheet or form to keep track of all your correspondence when you file an appeal. This will help you keep track of what needs to be done and what has already been done.
Tip 2: Put all letters, notes, copies, and records related to your appeal in one place so you can find information about it quickly.
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