When Coverage Is Denied

There may be times when your health plan denies a treatment or service. While the denial may cause confusion or frustration, there is a process in place with most health plans to file an appeal if you feel the service was wrongly denied.

Denials are issued if your plan does not cover the service or treatment you or your health care provider requested or if your plan determines that the care is not medically necessary.

By law, a 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?

Understanding what can and cannot be denied can make the process of filing a claim easier. Generally, coverage may be denied for the following reasons:

• Medical necessity: The treatment or service does not meet accepted standards of medical care and is not considered essential for diagnosis or treatment.
• Experimental or investigational: The treatment or service does not have established scientific evidence that it produces the desired result and does not meet accepted standards of medical care.
• Excluded benefit: The treatment or service is not offered contractually as a covered benefit under the health plan.
• 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.
• Cancelled or rescinded coverage: The insurer revokes or cancels coverage going back to the enrollment date because the health plan claims that false or incomplete information was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 to the health plan. 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, 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 preservice claim, predetermination, or prior authorization, it will communicate the decision verbally to the health care provider and follow up with letters to both you and your provider. If the insurer denies a post-service claim, you 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 the health plan reconsider, in a full and fair review, a decision to deny coverage of payment for a service.

It's important to note that you must file an 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 some cases, you can request a second-level appeal, or request for reconsideration. For individual and fully-insured employer plans, the next level is often an external review. For self-funded group plans, the next level might be an additional internal review.

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:

• Copy of your insurance card
• Completed external review form
• Copy of the letter from your insurance company stating that the appeal decision is final
• Letter of medical necessity
• Copies of supporting documentation

The external review may:

• 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 you are 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 prior authorization. This is a different issue that will require you and your physician to follow a separate process.

Increasing Your Chances of a Successful Appeal

To increase your chances of a successful appeal, include as much medical data as possible in a letter of appeal. If you have taken the denied treatment or therapy before and already have medical data showing that the therapy is working or previously worked, it is important that you include this information in the appeal as well. To help make your case even stronger, your letter of medical necessity should come directly from a physician at your CF care center.

Get Help With Compass

To learn more about claims and appeals, or to discuss if an appeal is appropriate, call CF Foundation Compass at 844-COMPASS (844-266-7277) .