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Gastric Bypass and Your Insurance, page 11
A 12-page report about gastric bypass and your health insurance
©2005 Jonni Good
“Grievance or Appeal” – What Does it Mean?
Somewhere in your benefit booklet or contract you will find a section that outlines your grievance or appeal rights. Some companies call the process a “grievance” and others call it an “appeal,” Regardless of what it’s called, the process will be pretty much the same.
Some insurance companies do not exclude gastric bypass surgery from benefits, but they turn down every pre-authorization request in the hopes that you won’t take the matter any further. When you file an appeal, they then take the time to actually consider the information you have given them and determine if you are eligible for coverage. This is, I hope, a rare occurrence, but you should be aware that it happens. If you believe you are eligible for benefits under your contract, don’t be afraid to fight for your benefits if you have to.
In some rare cases, usually with policies that are provided by large self-insured companies or unions, there are no appeal rights. The first decision that is made cannot be appealed. If this is the case, it should be stated in your benefit booklet. Even if it is the case, you may still have the right to appeal through your state’s Insurance Division. You can find your state’s Insurance Division by searching online.
If you do have appeal rights, (and most groups do allow this), there are certain things that you need to look for in your benefit booklet:
• How long can you wait to appeal after your original request for pre-authorization is denied?
• What documentation will you need to provide in order to have the original decision reconsidered?
• How many levels of appeal are available to you?
• Who will be making the decision when you appeal?
For instance, if your benefit booklet or contract states that you have 63 days to appeal a decision made by your insurance company, it is important to have your appeal letter and any available documentation in their hands before that time expires.
Your first appeal may be handled by the company’s Customer Service department. If this is the case, they will probably ask their Medical Services department to look at your documentation and compare it to the medical policy. It is possible that these are the same medical professionals who looked at your doctor’s pre-authorization request in the first place. This means that if the documentation is exactly the same, with no new information that would allow them to change their minds, your appeal is likely to be denied.
For this reason, it is important to do your homework. Make sure that you understand the exact reasons why your pre-authorization request was denied. If you were not given this information, call the insurance company and ask for it. If they are unable to supply you with this information, find out why not. (They may prefer that you discuss this with your doctor. If this is the case, make sure that your doctor has the specific reasons for the denial. You’ll need it when you make your case in the appeal process.)
Most of the time an appeal is a fairly informal proceeding, and no attorney is involved. However, if you feel that legal advice is needed, be sure to contact an attorney who is familiar with your state’s insurance laws. This report is not intended to replace legal advice.
It is possible that you can effectively appeal the original denial once you know the reasons for the denial. If one of the criteria listed in the medical policy has not been met, perhaps the insurance company simply needs more documentation from your doctor, or a letter of explanation. In other cases, you may just need more time – if the criteria requires documentation that you have tried a medically monitored diet for a year before becoming eligible for weight loss surgery, you may need to go on that diet, and be closely monitored by your doctor, before you’re eligible. After that time, a new preauthorization request can be made.
If you have a right to several levels of appeal, it may be necessary to go through the process more than once, in order to go high enough in the process to get an outside review board to look at your case. If this isn’t an option through your insurance company’s policies, you may need to send your second appeal to your state’s Insurance Division. Be sure that you approach each of these steps as thoroughly and professionally as possible.
I you provide all the necessary documentation, you know the procedure
is not excluded from your contract, and you meet all the insurance company’s
medical policy criteria – but your pre-authorization request and
your appeal are denied, it may be time to discuss your case with a qualified
attorney who specializes in health insurance law in your state.
Next Page of Gastic Bypass and Your Insurance Report
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