Getting your medical expenses covered by your health plan can be frustrating, but a little knowledge can go a long way.

The Basics

You can start by checking the following on your health plan:

  • Do you need a referral from your primary care physician in order to see a specialist?
  • Does the plan require prior authorization for a planned surgery or hospital stay?
  • Do you have to select a physician from a network for the charges to be fully cored?
  • What does your plan cover?
  • What does it limit or exclude?

Don't Be Stopped By Denials

If your health plan refuses to pay for treatment, you can and should consider appealing if:

  • The treatment isn't a covered benefit, but you think the health plan should make an exception for you, or
  • You have support from your physician that the treatment is "medically necessary," or
  • The treatment is deemed by the insurance company to be experimental or investigational.

Call the company that issued the denial, armed with a file of your medical and insurance information, including your benefit plan and summary.

A customer service representative can't overturn your denial, so ask to speak with a supervisor.

Making a Formal Appeal

Every managed care organization is required by law to have an appeal process.

Although an appeal process isn't perfect, it's much less of a financial and emotional burden than litigation. And your contract with the health plan may prohibit you from filing a lawsuit before filing an appeal.

When formally appealing:

  • First, read the appeal process guidelines in your policy. Familiarize yourself with timeline requirements.
  • Put your complaint in writing, including:

    Getting Help

    Your state Department of Insurance (DOI) has a wealth of information, including your rights regarding health insurance, the appeals process, whom to contact regarding an appeal and a general timeline for an appeal.

    You should be able to locate your state's DOI in the White Pages' state government section under "Insurance" or "Regulatory Agencies." Your state government's home page should have a link to the DOI.

    If you have questions regarding the mechanics of the appeals process:

    What's Next

    If the cost of the denial is enough to offset legal fees, it may be best for you to speak with an attorney who has experience with health care coverage and benefit denials.

    Heidi Frey founded the Patient Advocacy Coalition in Denver, Colorado.

    Insurance Claims Message Board for more help

  • Your health problems and treatment history
  • How you have exhausted all other reasonable alternatives
  • Physician recommendations
  • Why you are an ideal candidate
  • What will happen if treatment is not approved
  • Support letters from your physicians
  • Quotes from the benefit plan if it contains helpful language
  • Medical records that support your position.
  • Enlist your doctor's help. Your doctor willing to advocate for you.
  • Track relevant dates to ensure that your complaint is moving forward expeditiously.
  • Be prepared to spend a lot of time on the phone.
  • Keep a record of all communications, including the date and time of your conversation, the full name and title of the person with whom you spoke, and a summary of what was discussed.
  • If you're in a self-insured plan, which means that your employer has direct responsibility for medical costs, you should contact someone in your employer's human resources department for more information.
  • If you're in a Medicaid managed care plan, you may have special rights in the appeal process and you should contact the State Ombudsman or Medicaid customer service.
  • If you're in a commercial plan, which means that the managed care organization has direct responsibility for medical costs, the appeals process is outlined in your policy and follows state laws.

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