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PREPARING A FORMAL APPEAL

If your attempts to deal with the health plan informally are not successful, you will have to file a formal appeal.  Health plan procedures vary, but all will require details about your appeal to be submitted in writing.  Some plans allow you to initiate the appeal on the telephone, but then will ask you to complete a form and submit it before the process can continue.  If your plan does not provide an appeal form, consult your Summary Plan Description or the Evidence of Coverage for a description of the appeal process.  Look for specific information the plan needs to process your appeal.  Be sure to provide answers to all questions.  You don’t want to add to the delay by forgetting to supply crucial information.  Be sure to keep a copy of your written appeal.

Expect to provide the following information in your written appeal:           

  • Your name, address, telephone number,
  • Your insurance plan number or group code and member identification number or Social Security number,
  • Your provider’s name and bill,
  • Referrals to specialist services,
  • Description of the service or procedure that you want to have covered,
  • Information supporting why the service should be covered (including your symptoms and treatment history),
  • Recommendations and referrals from your doctor explaining why the treatment or procedure should be covered,
  • Explanation of Benefits (EOB) forms,
  • References to the sections of the Evidence of Coverage that apply to your situation,
  • Additional research on your medical condition or treatment, such as treatment guidelines, information from medical journal articles, or research that says the treatment is more cost-effective in the long term,
  • Documentation that the services are covered by the Medicare program or are required by state law.

You may have to file your appeal within a specified time period; it is vital that you do so.  For example, the health plan may say it must receive your appeal within one year of the date of treatment, or within 60 days of the date the plan tells you it’s not paying your claim, whichever comes first.  Federal ERISA regulations require that employer-sponsored health plans (both insured and self-funded) must give you at least 180 days to file an appeal.  Know your plan’s timetable for all stages of an appeal.  Again, if your dispute involves an urgent need for health care, make sure that you understand and follow any special procedures and timelines that apply in such cases.
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