How to Challenge an HMO's Denial of Coverage
Determine if you have been denied coverage by reading your insurance policy carefully., Read carefully through any pre-certification letter or Evidence of Benefits (EOB) statement that explains why your claim has been denied., Prepare your appeal by...
Step-by-Step Guide
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Step 1: Determine if you have been denied coverage by reading your insurance policy carefully.
Sometimes an HMO will need to investigate a claim further.
While its investigation is pending, the HMO may put a hold on the claim.
However, an insurance company failing to respond can also amount to an outright denial; it depends on your individual policy. -
Step 2: Read carefully through any pre-certification letter or Evidence of Benefits (EOB) statement that explains why your claim has been denied.
With your notification of denial, your HMO should provide information about how to appeal the decision.
If you believe your claim is valid, follow the appeals process outlined. , Write out the circumstances surrounding the claim and why the procedure is medically necessary.
Quote language directly from your insurance policy that will bolster your argument.
Include in your appeal that you intend to file a formal complaint with your state's department of insurance if the matter is not resolved in a timely manner.
Make several copies of your paperwork before sending one to the HMO. , Tell you doctor or medical facility that they are subject of the appealed claim.
This will (hopefully) prevent the HMO from sending the claim to collections while it remains in the appeals process.
Contact the HMO to ask if they received your appeal.
Make sure to document when you called and who you talked to.
You should also expect to receive a letter confirming the receipt of your appeal. , In a first-level appeal, medical staff employed by the HMO make the decision and the HMO will notify you of their decision in writing.
If the appeal is denied, you may be provided another appeal that is reviewed by a medical director employed by the HMO.
In a third-level appeal, the claim may be reviewed by medical professionals outside of the HMO. , You can find links to complaint forms on the agency's website that you can either submit electronically, or print out and mail.
The state department of insurance can conduct an independent review of insurance coverage denials.
In most states, HMOs are also required to submit patient complaints to the state department of insurance. , -
Step 3: Prepare your appeal by gathering the appropriate documentation.
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Step 4: Follow-up with the HMO and inform your doctor after you have filed the appeal.
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Step 5: Expect a decision on your HMO appeal within the time-frame outlined in your insurance policy.
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Step 6: File a formal complaint with your state's department of insurance.
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Step 7: Consult an attorney skilled in health care litigation to determine if you should file a lawsuit against your insurance company if you've exhausted your rights to appeal.
Detailed Guide
Sometimes an HMO will need to investigate a claim further.
While its investigation is pending, the HMO may put a hold on the claim.
However, an insurance company failing to respond can also amount to an outright denial; it depends on your individual policy.
With your notification of denial, your HMO should provide information about how to appeal the decision.
If you believe your claim is valid, follow the appeals process outlined. , Write out the circumstances surrounding the claim and why the procedure is medically necessary.
Quote language directly from your insurance policy that will bolster your argument.
Include in your appeal that you intend to file a formal complaint with your state's department of insurance if the matter is not resolved in a timely manner.
Make several copies of your paperwork before sending one to the HMO. , Tell you doctor or medical facility that they are subject of the appealed claim.
This will (hopefully) prevent the HMO from sending the claim to collections while it remains in the appeals process.
Contact the HMO to ask if they received your appeal.
Make sure to document when you called and who you talked to.
You should also expect to receive a letter confirming the receipt of your appeal. , In a first-level appeal, medical staff employed by the HMO make the decision and the HMO will notify you of their decision in writing.
If the appeal is denied, you may be provided another appeal that is reviewed by a medical director employed by the HMO.
In a third-level appeal, the claim may be reviewed by medical professionals outside of the HMO. , You can find links to complaint forms on the agency's website that you can either submit electronically, or print out and mail.
The state department of insurance can conduct an independent review of insurance coverage denials.
In most states, HMOs are also required to submit patient complaints to the state department of insurance. ,
About the Author
Samantha Lewis
Creates helpful guides on DIY projects to inspire and educate readers.
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