What to do if Denied Coverage

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