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.

Helping 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