Insurance Appeal Help

[garrettsmomma]

As many of you have done, I'm going to attempt to appeal the denial of coverage for Garrett's cranial helmet.

Does anyone have a sample letter? I found some online but they are all for plagio and that's not exactly what I'm looking for. Garrett had saggital synostosis and had the endo surgery - thus the need for the helmet!

I'm thinking my major point was the cost savings of having the endo done instead of CVR but any advice would be awesome!

I'm just not good at this stuff.

Thanks, Carrie

[Avery's Mom]

I would get your doctor involved...they should have something for you too. By the way love the new avatar pic. Don't you just love when they sleep with their little bottoms up? lol

[Laurie the IW]

You need to write an appeal. Insurance companies can smell a form letter a mile away. Form letters do not generally win appeals.

The first thing that you must do when anything is denied is to get your hands on a written copy of your insurer's "appeals and grievance" procedures. Without this, you have no idea what to do, where to send your appeal ... you have no idea where you are going.

You can find the appeals procedure in any one of three ways:

1. It is in your Plan Document, if you have a copy.

2. It may be on the insurance company's website. When appeals procedures ARE on the website, they are usually pretty well hidden.

3. Call the insurance company and say, "I am currently writing an appeal. I need a copy of the appeals procedure faxed to me TODAY." By most states' laws, they are required to send the appeals procedure in a timely fashion. Hold them to it.


The second thing to do is to find out if your have a self-funded plan, or a traditional plan. This makes all the difference in the world as to how you will write your appeal, and to whom you will send it.


Do not rely on your doctor to win your appeals. Doctors do not have as much power with insurance companies as we would like. YOU are the only one who has any traction with your insurance company.

I have written two books on how to write and win insurance appeals. It's not rocket science, we can all do it.

Laurie's motto: "Do what I say, and they will pay."

*****

By the way, I've been busy this week winning another appeal for one of the precious cranio kids. I will let his mom announce our great victory.

This makes me 3 for 3. Three appeals to get children to Dr. Fearon. I won each one of them in a week or less.

What can I say? I am highly motivated.


Cheers,

Laurie the Insurance Warrior