How to File Successful Insurance Appeals for MS Claims
When you have multiple sclerosis (MS), knowing how to get and keep your health insurance isn't enough. You also need to know how to file an appeal if your insurance plan refuses to pay for some or all of a treatment your doctor has prescribed for you — which can happen with a lot of the medications and services that are used to manage MS.
Many people don't pursue their right to appeal because they don't think they can win. But the fact is, when done properly, over 50 percent of appeals are successful.
Check your coverage.
Start by reexamining your health plan manual to make sure that what you thought would be covered actually is. If the service (such as physical or occupational therapy) or treatment (such as a medication) you need is specifically excluded by your policy, the chances of winning coverage for it on appeal are slim to none. If the policy doesn't specifically exclude it, however, using the appeals process is definitely to your advantage.
Confirm why coverage was denied or was less than expected.
Carefully review the explanation of benefits form — the insurance company's official response to your claim — to see why coverage was denied or is being reimbursed for less than the cost. These explanations often appear as codes, with explanatory notes at the bottom of the page or on the back.
If the problem requires a simple fix, such as correcting a code number or supplying a bit of missing information, make the change and resubmit your claim to the same place you or your doctor sent it originally. If everything's in order on the claim, and they're still denying coverage, your next step is to appeal.
File an appeal.
To give yourself the best chance at success, study your plan's appeal procedures (sometimes found in the section on grievances and appeals in your plan manual). It's important to follow these procedures carefully — especially the deadlines. Here are some basic guidelines:
Write a clear and simple letter. Give the facts and a concise explanation of why you believe your claim should be paid. This letter should be no more than one page.
Be sure to include your insurance ID number, the specific claim number (if applicable), the name and contact information of your healthcare provider, and the date of service (if applicable).
Keep detailed records. Health insurance policies and anything else that the insurance companies give you in writing are legal documents — so hang on to them.
Also, keep detailed notes about all interactions with your insurer, including dates they occur and names of company representatives you speak with on the phone. Save copies of claims and bills, appeal letters and any attachments, and other relevant communications.
Follow up. If your appeal is denied, go to the next level of appeal — don't assume that this happens automatically. The second appeal will still be an internal appeal, but it will involve a reconsideration of your original claim among a higher level of professionals within your plan.
If your second appeal is denied, you will be eligible for an external review of your claim by a panel of health professionals who have no affiliation to your health plan. Again, keep pursuing your appeal rights and submit additional information to strengthen your argument with every level of appeal. Contact your insurer, plan administrator, or state insurance department for additional information about your right to an external review.
Discuss your appeal with your healthcare provider. If the dispute is over the medical necessity of a treatment, your physician's input in the form of a letter that includes studies demonstrating the treatment's benefit will be invaluable. Make sure that your healthcare providers have a copy of your appeal letter on file, and let them know about the National MS Society's publication Health Insurance Appeal Letters: A Toolkit for Clinicians.