- 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
- 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
HOW TO MAKE A SUCCESSFUL APPEAL
WHAT DOES AN APPEAL PROCESS LOOK LIKE?
WHEN IS THE DEADLINE?1
- 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.
HOW TO APPEAL AND WHAT DO YOU NEED?
- 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
- Triage Cancer (2021). Quick Guide to Appeals for Employer-Sponsored & Individual Health Insurance. Retrieved
from https://triagecancer.org/quickguide-appeals. Accessed 4 April, 2022.
- Triage Cancer (2014). Health Insurance Appeal Tracking Form. Retrieved from
https://triagecancer.org/AppealTrackingForm. Accessed 4 April, 2022.
This health information is provided for reference only and is not intended to replace discussions with a healthcare provider.
All decisions regarding patient care must be made with healthcare provider.