When Coverage is Denied
Denials are issued if your plan does not cover the service or treatment you or your health care provider requested and/or if your plan determines that the care is not medically necessary.
By law, the health plan must provide written notification:
- Within 15 days for prior authorization requests
- Within 30 days of treatment
- Within 72 hours for urgent cases
What Can Be Denied?
Typically, coverage may be denied for the following reasons:
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Medical necessity: The treatment or service does not meet accepted standards of medical care and is not considered essential for diagnosis or treatment.
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Experimental or investigational: The treatment or service does not have established scientific efficacy and does not meet accepted standards of medical care.
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Excluded benefit: The treatment or service is not offered contractually as a covered benefit under the health plan.
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Out-of-network provider: The treatment or service is provided by a physician or facility that does not have a contract with the health plan.
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Cancelled or rescinded coverage: The insurer revokes or cancels coverage going back to the date of enrollment because the health plan claims that false or incomplete information was provided at the time of application for coverage.
What to Do Next
When appealing a denial of coverage, you need to work closely with your cystic fibrosis care team to ensure all required documentation is submitted.
Here are some basic steps you and your care team may take when coverage is denied.
Learn More About the Denial
If a health plan denies payment for a service, under the Affordable Care Act, the health plan is required to provide:
- The reason the claim was denied
- Information on how to file an internal appeal
- Guidance on the right to request an external review
- Contact information for any state consumer assistance program (if available)
If an insurer denies a pre-service claim or a prior authorization, it will communicate the decision verbally to the health care provider and follow up with letters to both the patient and the provider.
If the insurer denies a post-service claim, the patient will be notified by mail with an Explanation of Benefits (EOB).
File an Internal Appeal
An internal appeal is the formal process of requesting that an insurance provider reconsider, in a full and fair review, a decision to deny coverage of payment for a service.
It's important to note you have a limited amount of time to file an appeal. Department of Labor regulations require the filing of a standard appeal within 180 days of receipt of the denial letter. Once an internal appeal is filed, the health plan may:
- Overturn the initial claim denial
- Uphold the initial claim denial
In most cases, a member can request a second-level appeal. For individual and fully insured plans, the next level is often an external review. For self-funded group plans, the next level might be an additional internal level.
File an External Appeal
An external appeal is a reconsideration of an insurer's decision to deny coverage by an outside, independent organization. The external review is conducted by an impartial expert who is not a direct employee of, or who has no business relationship with, the health plan. If the case is urgent, it is recommended that you file an external review request at the same time as the internal appeal.
In most states, a written request for an external review must be filed within 60 days of the date the health plan sent a decision. Be sure to include all documentation required for the external review, such as a copy of your insurance card, a completed external review form, a copy of the letter from your insurance company stating that the appeal decision is final, a letter of medical necessity and copies of supporting documentation.
The external review may either:
- Overturn the health insurer's decision
- Uphold the health insurer's decision
External reviews are typically decided no later than 60 days after the request is received.
When to Pursue an Appeal
When considering an appeal, the first step is to ask your physician or CF care team if the denied service or medication is critical to your health. Anything that your physician feels is medically necessary should be considered for an appeal, particularly if there are any records showing that you need the treatment or if there are data showing that the treatment will help your health improve. Sometimes a claim may be denied because you need a prior authorization, but this is a different issue that will require you to follow a separate process.
If you are wondering whether or not you should pursue an appeal, you can start by discussing your denial with your physician, a member of your CF care team or a Cystic Fibrosis Foundation Compass case manager.
Increasing Your Chances of Winning an Appeal
In order to increase your chances of winning an appeal, you should be sure to include as much medical data as you possibly can in a letter of medical necessity. In fact, anything that shows medical data should be included in your file, as this will ultimately improve your chances of winning your appeal. To help make your case even stronger, you may want to have your letter of medical necessity come directly from a physician at your CF care center.
If you have taken the denied treatment or therapy before and already have medical data showing that the therapy is working or has worked in the past, it is important that you include this information as well. A health insurance plan is a contract between you and your insurance company, and an appeal implies a breach of that contract. Therefore, the strongest appeals are grounded in the specific benefits laid out in your insurance plan, with a primary focus on medical necessity.
If you need help getting through the claims and appeals process, a Compass case manager can offer you tips for filing an appeal and help you resolve any issues between you and your insurance provider. A case manager can also help you figure out what to do next if your appeal gets denied. To learn more about claims and appeals, call CF Foundation Compass at 844-COMPASS (844-266-7277) Monday through Friday, 9 a.m. until 7 p.m. ET, or email compass@cff.org.