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