How to fight your health insurer

The clock starts ticking on your appeal on the day you receive your denial in writing. Most health plans offer 30 to 60 days to appeal. Besides the notebook, you should assemble a file containing any paperwork you have already accumulated, such as bills, your explanations of benefits, copies of your letters, information from your physician and physician referrals.

The usual appeals process

This first stage in the appeals process can be broken down into three steps.

One: Get a complete copy of your plan coverage, not a two-page summary. Your employer's human-resources department should be able to provide you with this. Next, sit down with your letter of denial and highlight what benefits have been rejected. Then search for passages in your health plan that say your specific care is excluded.

Often you won't find information about coverage you've been denied. Sometimes treatments are not expressly excluded, but the contract may say something to the effect that "all other treatments are considered experimental and are not covered." At this point it's time to write a letter.

"Try not to be emotional and know that you are fighting a contract issue," Davenport-Ennis advises. In your letter, refer to your contract as well as the section in your plan coverage that indicates the benefit is covered. The more you can do this, the better your letter will be received, Davenport-Ennis says.

Bankrate.com provides sample letters for two types of claim denials as guidelines. One is an appeal for an out-of-network claim denial. The other is a form letter that can be used when appealing a denial based on a question of medical necessity. However, for your letter to be effective, you have to write it so it is your own.

Two: Contact your treating physician. Let the doctor know that you have received a denial and that you are appealing it. There is often a designated person at medical offices whose job is to handle insurance issues. You will be put through to a billing coordinator or someone who handles authorizations and appeals. Share a copy of your health plan with that person. Ask that the doctor write a letter on your behalf appealing the decision. If you had surgery and your claim was denied, have the doctor explain in writing why the procedure was necessary.

"If the claim was denied because it was deemed 'experimental and investigational,' know that these are only two words assigned by insurance company and are not based on science," Davenport-Ennis says. "The doctor is going to need to write a letter that explains concretely why this treatment for, say, a 10-year-old child with leukemia is appropriate for that child in that age group and hopefully refer to studies. Have them attach peer-reviewed literature that supports that treatment."

This is a tool that can effectively dispel and overturn denial based on the "investigational" denial.

Three: When both letters are finished, make copies for yourself, then send them to the insurer via registered mail. Record the date sent in your notebook. Check your plan coverage and note how long the insurer has to consider your appeal. If it says 30 days, then mark that you've got 30 days until you need to follow up.

Once your provider receives your written appeal, it will investigate and get back to you with a determination. At this stage it's called an internal review, a Level 1 appeal or a desk review, depending on the provider. Once the provider gets back to you with a determination setting out what the plan is willing to do, if it's not favorable, realize this was only the first step in the appeal process.

Video: Get your insurance claims paid

Emergency appeals

"If someone's life is at risk, perhaps with Stage 4 cancer, it's a very different matter," says Davenport-Ennis. "The first consideration is the health of the patient, and that person doesn't have 60 to 90 days to wait for an appeal."

Reach out for help immediately to overturn that appeal, because time can't be wasted. If you've got a child, the likelihood you'll get denials is somewhat reduced, she says, but if your child's claim is denied, don't pause for a second -- reach out for third-party help.

"For children, you don't know what is serious," Davenport-Ennis says. One child she knows of died from an abscessed tooth while the mother was fighting to get treatment covered.

If a delay in receiving services may cause serious harm, most states have an "expedited review," according to the Kaiser Family Foundation. A decision is made in a much shorter period, usually within 24 to 72 hours.

Continued: Where to find help

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