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What to Do When Your Health Insurance Denies Payment for Your Diabetes Care (Continued)

Step 2 - Ask for Internal Appeal of the Denial
What You Need to Know:

First, a simple error might have caused your claim to be denied. You have the right to information about why the claim has been denied, in writing, within:

• 15 days for prior authorization.
• 30 days for medical services already received.
• 72 hours for urgent care cases.

You also have the right to information about exactly how you can dispute the denial decision.

You have the right to ask for an internal appeals process. This process is a full and fair review of the insurer's decision and is conducted by the insurer. If your case is urgent, the insurer must speed up this process.

What You Need to Do:

• Call your insurance company immediately (number on back of insurance card) after receipt of the denial notice.
• Ask for an internal appeal. You must file this appeal within 6 months of receiving the denial notice.
• Contact your state's Consumer Assistance Program if you need help filing your appeals. The CAP's contact information is printed on the denial notice. You can find information at:  www.healthcare.gov/consumerhelp

Step 3 - Ask for External Appeal of the Denial

What You Need to Know:

You have the right to ask for an external review process IF the insurer says its first decision (during the internal appeal) was correct.  This process is conducted by someone outside of your plan, meaning a third-party independent reviewer. This review means that the insurance company does not get the final say over the benefit decision. It also means patients and doctors have more control over health care.

Your insurer is required by law to accept the external reviewer's decision. That means that when the reviewer says the insurer must pay your claim, your insurer must do so right away.

Some claims are not eligible for an external review.  If this is the case, you may still be able to get help with your appeal from your state's Consumer Assistance Program or Department of Insurance.

What You Need to Do:

Ask for an external review IF the insurance company says its first decision was correct. Do tell the agent that you believe that the decision was in error. Contact your state's Consumer Assistance Program if your claim is not eligible for an external review process. The Program may help facilitate another form of an external review process.

Step 4 - Be Calm, Positive, Persistent, and Thorough

Make an effort to be calm and positive throughout the appeals processes.  This will make the work for you and the insurer go more smoothly and could result in a more beneficial outcome on your behalf.

Take notes during all your phone conversations with your insurance company. Include in your notes:

• the name of the agent with whom you speak and the phone extension so you can contact him/her directly the next time you call.
• the date and time of each conversation.

Keep all your original insurance documents for your records and submit only copies to your insurer.  

Arming yourself with the information above, and adding a good dose of patience and persistence, your efforts to overturn a denied claim can definitely pay off.  

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NOTE: The information is not intended to be a replacement or substitute for consultation with a qualified medical professional or for professional medical advice related to diabetes or another medical condition. Please contact your physician or medical professional with any questions and concerns about your medical condition.