Health Insurance - I I'm forced to appeal the denial and don't know how to write an appeal that will get paid?

Question

Last fall I had surgery for deviated septum and nasal turbinates.

Doctors office called insurance company and obtadined automated approval.

Now the insurance company is refusing to pay for the chemical cauterization of turninates due to it being an investigational procedure.

Since it was an automated authorization, there is no one to go to that authorized procedure. Doctor office said they gave them the correct codes and was authorized.

I am now force to appeal this denial and have no idea how to write an appeal that will get this paid.

Anyone out there who could help?

Thank you very much in advance

Answer 1

Did the automated approval specify the exact procedure you had? If so, then send a letter by certified mail that says the following:



YOUR ADDRESS

YOUR CITY, STATE, ZIP



XYZ Insurance Company

Address

City, State ZIP



RE: Claim number XXXXXXXXX



I am writing to appeal the denial of a claim at the level of coverage detailed in the Certificate of Insurance, XYZ Insurance Company, Policy Holder XXXXX [name of employer, if employer-provided insurance], Policy Number XXX, Effective Date Month, Day, Year, Product Name XXXXX.





Please be advised that I requested and received pre-approval on [insert date you received the pre-approval] for [chemical cauterization of turninates].



However, the claim was not paid as of XXXX date.



Thank you for reviewing this claim and considering my appeal.



Sincerely,



YOUR SIGNATURE



YOUR NAME

Answer 2

Start by calling the administrator of your health plan. If it is through your employer, check with your employer to find out who the admin is, if it is just you buying the insurance, check with your insurance agent. Once you find out who is administering the insurance, call that person and ask them to explain the steps involved in appealing the denial Each insurance company is different. Follow the steps just as they are laid out. If they have any literature on the appeals process ask them to send it immediately.



Do all of this as soon as you can, since many companies have time frames in which you must appeal and carry out the necessary steps. If you miss a deadline, the appeal may be automatically declined and you will be out of luck.



Whatever you do, do not get discouraged and put things off.

Answer 3

Welcome to the American Health Care system....screwing people over since 1951.



If the money is worth it, hire an attorney or in your letter, let them know that you are getting an attorney. If you don't hear from them after you write your first letter, or don't get the response you want, write the CEO again. This time let him know that you are submitting your information to Michael Moore for his upcoming film "Sicko 2". Which of course will be bogus but maybe that will light a fire under their pants.



Otherwise, an attorney will be the only other person who can help you fight this.



Good luck and my thoughts are with you.

Answer 4

psychological well-being subject concerns are probable the suitable reason (or next to the suitable) for declinations of medical coverage purposes. the reason isn't basically for the situation itself, however the drugs can convey approximately undesireable visits to emergency rooms. Had an aquaintance bounce onto a shifting vehicle and smash the windshield along with his head. After that it became very sparkling why psychological well-being subject concerns are scrutinized lots.

Answer 5

You need to get a letter from the doctor, that says it's NOT an experimental procedure, that it's routine care. Then send that letter in, with a cover letter saying the same thing. It wouldn't hurt to get a second doctor to put that in writing, as well.

Answer 6

Does you doctor have an authorization number????

He, not you, should be doing this.He has all the codes at his fingertips., You don't.