Written by Tom Boyer and Stewart Perry, Diabetes Patient Advocacy Coalition
Highlights:
- You have the right to information about why a claim or coverage has been denied, the right to an internal appeal with your insurer, and the right to an independent review once internal plan appeals are exhausted.
- The appeals process has three levels: First-Level Appeal/Internal Appeal, Second-Level Appeal, Independent External Review. Your insurer must make a decision on the appeal within 30 days for prior authorization, within 60 days for medical services already received, within 72 hours in urgent care cases.
- The Diabetes Patient Advocacy Coalition (DPAC), aims to ensure that patients have access to the care and medications they need to live.
Has your health insurer ever told you that a medical procedure, necessary medicine, or medical equipment like an insulin pump or glucose sensor will not be covered by your policy? Odds are, yes. A recent survey published by the Kaiser Family Foundation found nearly one in five adults reported experiencing a medical claim denial over the past year. Another study found some plans deny nearly a third of claims. Infuriating? Yes. But it can be empowering too.
Why empowering? Because knowledge is power. Knowing the likelihood of a denial for a medical claim helps you prepare for the day when you receive an email, letter, or phone call from your insurer informing you that something your doctor tells you is necessary for care will not receive insurance coverage.
What to Do If Your Insurance Claim Is Denied
What should you do if you experience a denied claim for medical care including endocrinology visits, lab tests, glucose sensors, insulin, or other medical needs? As a first step, consider visiting this website established by the Center for Medicare and Medicaid Services (CMS) which provides an exceptional overview of insurance denial appeals processes. The tips afforded on the CMS website and throughout this article apply to all types of health insurance plans, be they private insurance, Medicare, Medicaid, and other forms of medical insurance like those for dental care.
How To Prepare an Appeal for Your Denied Claim
Know Your Rights
The Affordable Care Act, sometimes called the ACA or ‘Obamacare,’ established a framework for appealing denied medical claims. This law also established a series of fundamental rights: the right to information about why a claim or coverage has been denied, the right to an internal appeal with your insurer, and the right to an independent review once internal plan appeals are exhausted.
Research Sample Appeal Letters
Search online for guides and model letters to help you file internal and external appeals. Healthcare.gov, the California Department of Insurance, the California Department of Managed Care, Washington State’s Insurance Commissioner, and others publish guides and model letters you can potentially use that may help guide you during an appeal. Here are two sample letters:
Keep All Documents and Communication
Keep, file, and review all notifications received from any party related to the claim – in letter or electronic form. You may need these items at a later date to substantiate your position and your need for care, be it prescribed or given.
Understand Your Plan’s Appeal Process
Yes, each plan must allow you to appeal any claim denial and rule on your appeal in a timely manner. In most cases, timely is defined as within one year’s time from when the denial is issued. However, you have other rights where in urgent situations you can file and press for an emergency appeal in life-threatening or life-altering situations. In such situations, a health plan must rule on your appeal within 48 hours or two business days. If you believe or determine a denial is inappropriate, be meticulous in understanding the process and guidelines your insurer obligates you to follow in filing a claim. Then, act without delay.
Be Consistent and Persistent
Should you file an appeal, be consistent and persistent. And maintain a record of all conversations and communications with your insurance carrier. It may make sense to have a notebook handy to identify the date and time of your communications along with the name of the insurer’s employee with whom you are communicating.
Overview of the Appeals Process
The appeals process has three levels:
- First-Level Appeal/Internal Appeal: You (or your doctor) contact your insurance company to request that they reconsider the denial.
- Second-Level Appeal: The appeal is typically reviewed by a medical director at your insurance company who was not involved in the claim decision.
- Independent External Review: An independent reviewer with the insurance company and a doctor with the same specialty as your doctor assess your appeal to determine if they will approve or deny coverage.
If your situation is urgent (your health is in jeopardy or if you’re experiencing pain that can’t be controlled while you wait for an internal appeal decision) you can ask for an expedited review.
How to file an internal appeal:
- Complete all the forms required by your insurance company to request an internal appeal, or write to your insurance company with your name, claim number, and health insurance ID number. In the letter, make sure to say that you are appealing the insurer’s denial.
- Submit any additional information that you want the insurer to consider, such as a letter from your doctor.
You must file your appeal:
- Within 180 days of receiving notice that your claim was denied.
- In writing, or, when your need for care is urgent, over the phone.
For urgent health situations, you may ask for an external review request at the same time as your internal appeal request.
How Long Does an Internal Appeal Take?
Your insurer must make a decision on the appeal:
- Within 30 days for prior authorization
- Within 60 days for medical services already received
- Within 72 hours in urgent care cases (or less, depending on the medical situation)
You have a right to see and respond to all information used in the internal appeal decision.
External Appeals
After exhausting your health plan’s internal appeals, consider asking for an independent external review. Another right afforded by the ACA or ‘Obamacare,’ an external review places the power of determining whether care is necessary or appropriate into the hands of an independent body. Placing the power into the hands of others outside your plan theoretically gives a patient and their healthcare team more power over charting the course of care.
Special Considerations for Insulin Denials
Never leave a pharmacy after experiencing problems at the counter getting your prescribed insulin, unless you have another plan to get your insulin as soon as possible. Getinsulin.org is a great resource to help you find savings programs to help you get insulin on the spot at an affordable price or even for free. You should also ask your pharmacist if an equivalent insulin is available on your formulary or health insurance plan at a more affordable price.
Closing Thoughts
A little planning can go a long way in preparing for and overcoming health insurance denials. In your appeals, we encourage you to be personable, professional, and perhaps most importantly, persistent.
Our organization, the Diabetes Patient Advocacy Coalition (DPAC), aims to ensure that patients have access to the care and medications they need to live. Advocacy happens at the pharmacy counter, in the doctor’s office, in the workplace, and on the national stage. We are here to amplify and elevate your voice: sign up to be a champion and learn more here.
Additional Resources:
What You Need to Know About Navigating Insurance and Changing Plans
Demystifying Health Insurance Part 1: How to Pick a Plan with the Lowest Total Cost
Demystifying Health Insurance Part 2: The Three Ds of Selecting a Plan
Demystifying Health Insurance, Part 3: Decoding Health Insurance Plans
What to Know Before Making the Transition to Medicare If You Have Diabetes
I use Afrezza, which my Medicare Part D plan covers this year.
My plan for next year, with the same company, Cigna Health, is the same plan but with a higher premium. It says Afrezza will not be a covered medication. I suppose that means it’s non-formulary. Is the maximum that I will have to pay for it still $35.00 from the pharmacy even if I don’t use my insurance? Is the maximum that I will have to pay for it $2,000.00 out of pocket? And then it’s free after that?
Hi Barry,
We reached out to one of our contacts at Mannkind, and this was his reply:
“Although Afrezza is not on your Medicare Part D plan formulary, it is currently being covered by virtue of a prior authorization or a medical exception. That prior auth was likely issued for a term of one year. When your new insurance plan becomes effective in 2025, you will need to have another prior authorization submitted and approved to continue receiving Afrezza for $35 per month. This is true for all Medicare Part D plans.
As of 2023, the Inflation Reduction Act states that the copay for Medicare recipients will be no more than $35 per month for a covered insulin throughout the entire year. A Medicare patient taking Afrezza will not be required to meet their deductible before getting it covered at $35. It is a $35 copay on day one. If a patient with Medicare fills a prescription for Afrezza before meeting their Part D plan’s deductible, their cost-sharing amount ($35) will be applied to their deductible.”
Hope that helps!