Insurance Appeals and Denial of Coverage

Insurance companies often deny payment for issues like medical necessity, non-covered benefit, no pre-authorization, non formulary medication, out of network and more.  When these issues arise there is only one thing that you can do, appeal ...appeal …appeal! 

Insurance companies deal with member grievances through their internal appeals process.  To begin an appeal, you simply need to contact the insurance company and state that you would like to appeal the denial of coverage.   While this is a simple thing to do, HealthCare Advocates does not suggest taking this approach.  Why?  Because appeals are like little court cases, if you do not win your case, you don’t get to start all over again.  Further, if you decide to initiate litigation (sue the insurance company) at a latter date, you will likely be constrained to using the materials that were used by the insurance company when rendered a decision on the appeal/grievance. 

HealthCare Advocates fights insurance companies everyday when people receive an underpayment or a denial of coverage for things like medical necessity; no pre-authorization; the plan begin canceled for non-payment or late payment.  The most important thing to note is that HealthCare Advocates has the experience to be successful.  While many intelligent people try to fight the insurance company, they forget one thing – intelligence does not replace experience!  And HealthCare Advocates has the experience to be successful for you! 

There is one additional advantage to using HealthCare Advocates, our letterhead.  As told to us by a former Aetna Appeals Specialist, “when we get your [HealthCare Advocates’] appeals they go into a special pile.  The reason is that we know they are vetted.  To often members appeals are bad and they appeal for things like a motorcycle helmet because a helmet is health related.  With you [HealthCare Advocates], we know the issue has been vetted and is real.  That makes our jobs easier.”