Medical insurance helps many patients obtain the treatment or surgery they need. There are times, however, when your insurance provider might not agree with your doctor's recommendation. Knowing how to communicate effectively with your insurance company can be the first step toward a successful claim resolution.

Communicating With Your Insurance Company

Your health insurance policy is a contractual arrangement between you and your insurance company. Your policy will list the services that are covered and those that are not, and both you and your insurance company are bound by the terms of the agreement.

The way your relationship with your insurance company should work is:

  • Your doctor recommends a treatment or surgery.
  • You or your doctor file the paperwork to get medical services pre-certified with your insurance company.
  • An insurance company representative notifies you or your doctor that the treatment is covered.
  • You undergo the treatment or procedure and your insurance company pays for it, less any co-pay or deductible.

Sometimes, your insurance company may not be willing to provide coverage for a treatment or surgery. Possible reasons include:

  • The treatment or surgery is specifically not covered under the terms of your policy.
  • You have exceeded your benefit level.
  • The treatment may be covered, but with restrictions. For example, you may be required to go to a doctor within your insurance provider's physician network. Or, the treatment may be covered, but only for a specific diagnosis.
  • Your doctor is recommending treatment that involves new technology that your insurance company considers experimental or investigational.
  • Your insurance company has determined the treatment is not medically necessary.

Insurance companies are required to provide covered members with a process for reconsideration and review of any adverse decision or claim denials. They also must provide information about this review process. When policy holders receive the right information according to the insurance company's policies and procedures, they are often able to overturn a claim denial.

The Appeals Process

Each insurance company has its own appeals process; however, there are some general guidelines that apply throughout the industry.

Typically, there are three levels of appeal:

  • Level 1 – First-level appeals are usually processed and reviewed by the insurance company's appeals staff or by the insurance company's medical director responsible for the denial.
  • Level 2 – Second-level appeals are reviewed by a medical director not involved in the original claim decision.
  • Level 3 – Third-level appeals are usually completed by an independent, third-party reviewer in collaboration with a physician who is board-certified in the same specialty as the patient's physician.

Getting Started: To Appeal or Not to Appeal

First, carefully review your denial letter to determine why your claim was denied. If your claim was denied because your insurance company needs more information, you may not need to appeal, but simply gather the information and submit it according to the company's policies and procedures. Your physician or his or her office staff may be able to assist you if needed.

You probably should NOT appeal if:

  • Your insurance policy specifically excludes coverage of the exact procedure your physician has recommended.
  • Your lifetime benefit is exhausted.

You may want to appeal if:

  • The procedure your physician has recommended is different from the one cited in your denial letter.
  • The denial is based on new technology or lack of proven medical necessity and your physician considers it the best treatment for your condition. (Ask your physician to provide peer-reviewed research to back up the diagnosis and treatment plan and, if possible, any clinical outcomes data.)

Getting the Help You Need to Prepare Your Appeal

If you do decide to appeal, you will need to communicate clearly your reason(s) for doing so, and be able to produce documentation to support your claim. This might include a Letter of Appeal (from you or your doctor) and a Letter of Medical Necessity (from your doctor), and any other paperwork your insurance company may require. In instances where new technology is an issue, you may want to include copies of peer-reviewed journals and clinical outcomes data regarding the treatment that has been denied coverage.

First, refer to your insurance policy booklet and talk to your insurance company representative about your claim, then:

  • Confirm timeline/deadline requirements; if you need an expedited appeal, emphasize this to your representative.
  • Identify a contact person/representative (this is usually the person who signed the denial letter).
  • Make sure you understand your insurance company's appeals procedure.
  • Keep complete records of all correspondence and telephone conversations regarding your appeal:
    • What did you discuss? What was the outcome of the call?
    • Record names and titles of everyone you speak with.

You also may enlist the help of your physician and/or his or her office staff in resolving your claim. Ask your doctor to call your insurance provider and speak directly to the medical director or case manager involved in your claim.

If your medical insurance is provided by your employer, contact your company's human resources department for assistance. If your company's insurance provider is refusing to cover a medical treatment recommended by your physician, your human resources staff will want to know. Ask for their help in handling your appeal—sometimes a phone call from your employer to the insurance company can make a difference.

There are also some government agencies that can help. If you believe your insurance company is not furnishing the guidelines you need, you can contact your state's insurance commission, your local Division of Consumer Affairs, or Office of the Ombudsman for assistance.

Your Appeal Letter: The Key to a Successful Claim Resolution

A clear, concise appeal letter is one of the most important elements of your submission to the insurance company.

Your physician may offer to write the letter, but if you are writing your own, here are a few guidelines to consider:

  • Be pleasant and informative; describe your medical condition and the impact it's had on your life.
  • State plainly why you need the treatment or surgery.
  • If your need for the treatment/surgery is urgent, state in bold letters that your claim needs to be expedited.
  • State the reason(s) you believe your insurance policy covers the treatment/surgery.
  • Use your own words, not legal phrasing or catch phrases.
  • If you are not appealing all of a denial, state clearly which portion you are appealing.
  • If there is some compelling evidence the treatment/surgery will save the insurance company money on future expenses, such as physical therapy or medication, point it out.
  • Provide clinical data, such as published research, medical journal articles or clinical outcomes data, that shows the benefits of the treatment/surgery.
  • Include all contact information for both you and your doctor.
  • Clearly state a timeline for contact based on the guidelines you've been given; expedited claims have a different set of timelines.
  • Ask your doctor to review your appeal letter and make any revisions if needed.
  • Send the letter by certified mail, return receipt requested.
  • Keep a copy of the letter, the delivery receipt, and a record of all correspondence (written and verbal) preceding and following the mailing of the letter.
  • Insurance providers are required to respond to a written appeal letter. You should receive a notice stating your appeal has been received. If you do not receive a notice within 7-10 days, contact your insurance company representative to find out if your appeal has reached the right person.

If you would like to write an appeal letter but don't know where to start, here's a sample appeal letter.

Medtronic is focused on improving patient access to our therapies and technologies. As a result, Medtronic’s Spinal and Biologics business provides a service, Therapy Access Solutions (TAS), to assist in navigating the authorization and appeal process with payers. This program offers information, training and support for our customers. Contact the TAS staff at (866) 446-3873 for assistance with prior authorizations, denial management and appeals, office staff education and training, and product information.

The intent of this information is to provide you with the general framework and processes you should be aware of when appealing a coverage denial by your health insurance company. Each insurance provider has specific policies and procedures for handling subscriber/member appeals. These policies and procedures vary from company to company. Please refer to your insurance policy or contact your insurance provider's customer service department to obtain specific information about its appeals process.