Evaluate the Result
If you receive a phone call or a letter informing you that your denial has been overturned and the insurance company will cover the procedure, Congratulations! Before you celebrate you need to request a copy of the approval letter. You also need to be sure that you are aware of any conditions that are included. For example, you may get an approval to have the surgical procedure, but the insurance company may only cover it if it is performed by one of the doctors in their plan that you have never seen. If the conditions are unreasonable and unacceptable to you, discuss them with your doctor and insurance contact person. You may consider continuing with the appeal process. Most plans have several levels of appeal.
If your appeal has been denied, you also need a copy of the second denial letter. Like your original denial letter, this letter must also contain the specific reason for denial. Read the letter carefully. It may have a different reason for the denial. For example, the original denial letter states that a bone marrow transplant was denied because it was not effective for the disease, and was to be performed 'out-of network'. You submitted your appeal and all the appropriate documentation. The second denial letter rejects the procedure because 'there was not enough evidence provided to show that the transplant is medically necessary'. These are very different reasons for denying the same procedure.
Typically, the second level of appeal will be reviewed by a different group of people at the insurance company. Usually your second denial letter will explain the reason for denial and may even ask that you submit specific information that was not received with your first appeal letter. Be sure to notify your doctor of the decision and the new information that is needed. This denial letter may instruct that if you are interested in appealing further that you send your letter and new information to a different person. If you decide to continue with the appeal process, you should submit another appeal packet with new information specifically addressing the current reason for denial. Again, keep copies of all information and send the packet registered mail, return receipt requested. If your appeal is again denied, you should request the third denial in writing and notify your doctor. If you believe your insurance company should cover the procedure and are willing to proceed with the appeal process, you should refer to your plan document for the next step.
At this point some insurance companies will offer you what they call an 'external review'. This means that the insurance company will send your appeal to a company that they contract with who will review the denial, the appeal, and any new information and make a recommendation to the insurance company about the procedure in question. The external review board is typically made up of nurses, attorneys, and doctors who specialize in the specific procedure you are asking the insurance company to cover. In some states the law allows the patient to request that your case be sent for an external review.
If you live in a state who has an external review board, you can contact the state department of insurance for further information.
While external review can be very beneficial, it is important that the limitations are clear. The external review company can only act within specific parameters. They cannot override your policy. They can make decisions based on your policy guidelines. For example, you need to have surgery and want an 'out-of-network' doctor miles from your town to perform the surgery but you have a policy with no out-of-network benefits. Your insurance company agrees that you need the surgery and has an in-network surgeon in your town. If the surgeon in your town is in-network and is qualified to perform the surgery the external review board would probably not be helpful because of the nature of your request. However, if you and your surgeon believe that the surgeon in your town is not qualified to perform the surgery for a specific reason and you can support this with the necessary documentation, the external review board may be able to substantiate your claim. That may result in the insurance company overturning your denial.
At this point, if you have exhausted all the levels of appeal and are not satisfied with the decision, your remaining alternative may be to pursue the issue in court.