What should I put in my appeal for an insurance claim denial?

Appeals require some combination of these essential elements:

• Initial evaluation for a plan of care and measurable goals
• Progress report
• Prescription with diagnosis, frequency of service, session length, and treatment duration
• Office visit or daily treatment notes
• Letter of medical necessity from your child’s therapist or physician
• Summarizing cover letter

Offer the writing physician a letter template with a header containing all the relevant plan information, ID number, and any group number with a list of points that you would like made. Include a copy of the denial or the report of the service provider treating your child. Give your therapist or physician ample time to generate the needed documentation.

In California, if you have filed a grievance at the plan level and they are still saying no and you know it is incorrect, you can appeal at one of three places (on the paperwork with your denial from the insurance company):

• Department of Insurance
• California Department of Managed Health Care (It has even fined health plans for their behavior)
• Independent medical review (They are actually independent, and they review both sides. This is most common for self-insured plans.)

All three make decisions that are binding, so all the way through the process, make succinct and accurate arguments that are clear. When writing your argument for why your claim should not be denied, plan for the argument to be read by someone at the appeal level. Make sure you write in a way that may be observed and read by someone else.

Undivided Director of Health Plan Advocacy Leslie Lobel says that you should be strong and direct, but don’t get so wedded to your argument that you don’t read and respond accurately to the reason the plan denied. Whatever denial you get from the plan, make sure that you are clear on WHY they denied, and respond to their specific denial. If they deny for more than one reason, respond to each reason and be spot on.

Understand that it is a difficult process so that you know what you are getting into. It may not be worth it for one service but worth fighting for a different one. It may be worth going with the provider you don’t love in one area so that you can focus your energy on getting a different specific provider covered, as it is a lot of work. It’s important to protect your energy and make sure that you are spending it in areas that have the most chance of paying off.

For more tips about dealing with insurance claim denials, see our article Insurance Claim Denials and Appeals 101.