HOW TO MAKE A SUCCESSFUL APPEAL
Your insurance company may deny your claim at some point. But what if you find the reasoning for denial unacceptable?
Luckily, you can file an appeal for the insurance company to revisit your claim. However, making an appeal can be an overwhelming process. The following information may guide you through the process.
WHAT DOES AN APPEAL PROCESS LOOK LIKE?
Statistics show that millions of claims are denied annually. Unfortunately, many patients accept the denial because they don't know they can plea their cases. This is a shame - over half of those who file an appeal are eventually granted medical coverage!1 So, don't be afraid to assert your right using these two chances:
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Internal Appeal: This is an appeal to file with your insurance company. Since each insurance company has their unique internal appeal process, you need to contact your insurance company for all the information.1
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External Appeal: For when your internal appeal is denied. An independent reviewer will see if your treatment is medically necessary for you. If the answer is "Yes", your insurance company must cover the expense.1
Be it internal or external, you can file three types of appeal: pre-authorisation appeal, post-treatment appeal, and expedited appeal. An expedited appeal is for when you need a quick decision, such as when you urgently need pre-authorisation for critical treatment.1
WHEN IS THE DEADLINE?1
Beware of deadlines for filing an appeal. Deadlines for filing and getting a response for an appeal may vary across different insurance companies, and the following information is general guidance. Contact your insurance agent for details.
You must file an internal appeal within half a year of receiving the claim denial letter. If your internal appeal is denied, you must file for an external appeal within four months. For an expedited appeal, you can file both internally and externally at the same time to receive medical treatment promptly.
In return, your insurance company must also answer your appeal before the deadline:
- Internal Appeal: for a pre-authorisation appeal, the insurance company must decide within one month. For a
post-treatment appeal, they must decide within two months.
- External Appeal: independent reviewers must answer both pre-authorisation and post-treatment appeals within 45 days.
For expedited appeal, both the insurance company and independent reviewers must give you an answer within 72 hours.
HOW TO APPEAL AND WHAT DO YOU NEED?
After you map out the deadlines, you should follow this step-by-step appeal process guide:
- Once you receive a claim denial letter, you must check the reason for denial. Contact the insurance company if the reasoning is not detailed enough.1,2
- Ask your healthcare team for supporting documents that explain why your treatment is medically necessary - this will become your main argument in the appeal.1,2
- Fill in the internal appeal form. Then, send the form and all necessary evidence to your insurance company. You will probably need these pieces of evidence listed, although you should seek out information on what evidence you need precisely:1
- Supporting documents from your healthcare team
- Documents on medical treatment procedures and/or results
- Academic papers and studies showing the effectiveness of the medical treatments on your condition
- A letter describing your condition and why you need this treatment
Hopefully, your internal appeal is approved. If not, please repeat steps 1 to 3 or file an external appeal and receive a decision from an independent reviewer.2
TAKE NOTES:1
Making an appeal is a meticulous process. You should file all relevant paperwork and evidence. Create a checklist to make sure you do not forget anything. Keep notes of the names of representatives you have talked to and the topics of the conversations – these notes will be helpful when you need more details.
You can also ask your caregivers, families, and friends to help with keeping track of paperwork, phone calls and deadlines. More help can lead to more thorough preparation, making your appeal more likely to be accepted.
