Submitting an Appeal

How do I make an appeal?

  • Call your insurance company regarding the denial. The process for appealing a denial will vary among health plans, but here are some general things to remember when calling:
     
    • Request a copy of the denial if you do not already have one.
    • Inform your insurance company that you wish to appeal their denial.
    • Ask about the appeal process.
       
        • Why was the prior authorization or claim denied?
        • Who must initiate the appeal (you or your provider)?
        • What is the appeal process?
        • How long will it take to process the appeal?
           
  • Write an appeal letter. In most cases, you or your physician (or physician's staff) will be required to write an appeal letter.

    The purpose of an appeal letter is to tell the insurance company that you do not agree with their decision and the reason you believe the service or claim should be covered.

    In this letter, be sure to include the following information:
     
    • Your insurance information, such as your policy number and group number, so that your account is easily identifiable
    • A summary of the denial based on the denial letter you received and your discussion with the insurance company
    • Your medical history related to your diagnosis (your physician may be able to provide information from your medical chart)
    • Any medical treatments previously tried for the conditions and the results
    • An explanation of why your insurance company should reconsider their denial and approve coverage

    A letter of medical necessity from your doctor may or may not be required with your appeal. If this is required or recommended by the insurance company, they may also request copies of your medical records to accompany the letter of medical necessity.

    Even if not required, a letter from your physician can be very helpful in supporting your position. No matter what type of insurance you have, it is your right to appeal a denial.

    Read a sample letter used to successfully appeal an insurance company’s decision.
  • Copy your appeal for your own records.

  • Submit your appeal, including any additional letters.

  • Call to confirm receipt of your information with your insurance company and inquire as to how long it will take them to review your information and make a decision. Based on the time frame they provide, you will want to follow up periodically to check on the status of your appeal.
     
  • If your appeal has been denied, you should request a copy of the denial letter. This letter should include an explanation of the reason for denial and may even request additional information. The letter should also provide guidelines on further steps if you would like to appeal this decision.

    If you feel as though your insurance company should cover your treatment, even after it has been denied, you can file a grievance with the Department of Insurance.


Contact us with insurance questions, success stories or suggestions.
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The information provided on the PHA website is provided for general information only. It is not intended as legal, medical or other professional advice, and should not be relied upon as a substitute for consultations with qualified professionals who are familiar with your individual needs.

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