Insurance Denial Letters: Basic Strategies

OK, you received a denial letter from the insurer. Calm down first, please. Read your letter again, look up the denial code on the bottom or on the back. Then pull out the policy manual that explains that provision.

Sometimes it is something very simple to fix. In fact, I will say that most of the time it is something very simple. Most denials for the reason of 'no demonstrated medical necessity', can be cleared up by giving the name of a referring doctor.

Sometimes all you have to do is call the customer service line, and give them the doctor's name who ordered or authorized the procedure. In some cases, you may have to do this by mail; be sure to enclose the doctor's original prescription ordering the test or whatever, or a copy of a doctor's letter of medical necessity which you have cagily kept on file for problems like this.

For more involved appeals of denials on the basis of experimental or investigational procedures will require you to send in the letter of medical necessity plus two articles from established medical journals that detail the success of the proposed treatment. Examples of established medical journals are JAMA (Journal of the American Medical Association), the New England Journal of Medicine, and Lancet (British).

Some articles may be found by searching on LookSmart at find articles.com. You may find it helpful to order actual Appeal Letters from HealthSymphony online. They charge a fee for each appeal letter, but the form covers a slew of common denial reasons and will help you to organize your response.

Go to Symphony Group and order whichever form appeal letters you need. Also a great newer site is RevolutionHealth.com started by Steve Case, and it has a page on your rights and how to document and contest an unfavorable decision by your insurance company at Revolution Health. I like the part where it tells you to ask about the medical training of the person who denied the claim.

Check this column for related articles as I write about specific denials and specific strategies for fighting them.

[The author has worked in the insurance field in several roles for a decade, and now chooses to make information available to consumers. Stay tuned for articles detailing your consumer rights.]