What to do if Denied Coverage
What are some common reasons for denials?
- Process Errors:
- There was a missing authorization code.
- The paperwork was not filed in a timely manner.
- A payment was not received.
- Coverage Issues:
- You went to an out-of-network provider.
- You aren’t eligible for the service/medication.
- The medication/service was not pre-authorized.
- You may have been impacted by a step therapy protocol.
- The services were not appropriate/authorized/deemed medically necessary.
Helpful tips for writing an appeal letter
- Clearly state at the top of the letter that the purpose of the letter is to appeal a decision. Include only facts (not emotions).
- Information in the letter MUST be related to reason for the denial.
- Include policy number, claim number, date of service, and complete contact information (home address, phone, and email).
- Check for spelling/grammar errors.
- Send copies of documents — NOT the originals.
- Include letters from treating physicians showing medical necessity as well as copies of relevant medical records/information.
- Include a personal statement.
Helpful tips for sending an appeal letter
- File it quickly and pay attention to dates – there can be time limits on how quickly you must file an appeal after a claim is denied.
- Keep all copies of correspondence from yourself, your provider AND the insurance company.
- Keep a record of all names/titles of everyone you speak to, and any case or authorization numbers.
Appeal letter templates
The Crohn's & Colitis Foundation offers a variety of sample letters/templates you can download and customize. Click here to to access any of our appeal letter templates.