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Patient Appeal Process after Insurance Denial of Pre-Determination Request(s)

Now that your doctor has exhausted all of his or her pre-determination request appeals, what can you do?  You, as the patient, have the right to appeal the denial(s) and you should pursue this option.  Some patients have been successful in getting their insurance company to pay for their treatment using the appeals process.  You will need to work closely with your doctor to pull together a compelling request with supporting medical information to appeal the denial(s). 

Most health plans have a patient appeals process. Contact your health plan for details about the patient appeals process.  Here are some important items to ask about:

  • What is the deadline for filing my patient appeal?
  • What type of supporting paperwork am I required to submit with the patient appeal?
  • Are there any special forms I am required to use to submit the patient appeal? 
  • How many times can I submit an appeal?
  • What is the deadline for the insurance company to respond to my appeal?
  • How will I be notified of the insurance company’s response to my appeal?

It’s very important to find out right away what is your insurance company’s deadline for filing the patient appeal.  Most states mandate the timeframe in which patient appeals must be processed.  Your insurance company can tell you what that timeframe is.  Make sure to submit your appeal before the deadline.  Once you file your appeal, the health plan must respond to you within a specific time period. 

Consider sending the appeal letter and supporting paperwork by certified mail and request a confirmation of receipt.  Alternatively, you may call the insurance company to confirm receipt.  Make a copy of what you submitted for your records.   If you make any phone calls to the insurance company, document the date, who you spoke with and a summary of the conversation.  

 

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