Keys to a Successful Appeal

The appeal process is designed to ensure that all critical decisions affecting your care – including whether you receive TomoTherapy or Radixact treatment – is given the consideration it deserves. There are five steps that can be taken to give you the best chance to overturn a denial.

Understand the Payer’s Reason for Denial – Understanding the payer’s reasoning for denial is very important because it will help you and your doctor develop an appropriate approach for a successful appeal and gather the necessary supporting documentation. In cases where coverage is still denied, their letter of denial may give one or more of the following reasons why the payer will not cover your treatment such as:

  • The treatment is investigational or experimental
  • The treatment is not medically necessary
  • The treatment is not the standard of care

 

Appeal in writing – You must send a letter to the payer requesting that the coverage decision be reversed. The letter should be written within the deadline mentioned in the denial notice, typically within one to four weeks, and it should contain relevant information about you, your condition and the treatment.

Get Your Doctor Involved – You can ask your doctor to call the payer or send a second letter seeking reconsideration of the denial. Sometimes there will be a faster response when a doctor personally calls the medical director of the insurance plan. Also, the doctor can send a formal letter requesting coverage approval and submit supporting documentation on the medical necessity of the treatment. The letter should contain information that may not have been included in your letter, such as medical details and clinical efficacy of the treatment.

Be Persistent – You should be persistent and follow-up with the doctor, reimbursement administrator and payer staff on all correspondence and progress. Often, the doctor’s staff is willing to help, but it is important for you to be in charge of the process and take responsibility to keep it moving along.

Keep Good Records – You should maintain proper records and documentation, and ask the doctor for copies of any correspondence that he or the office staff presented to the payer. You also should keep track of each contact you make with the doctor, office staff and payer. It’s important to note the date, contact person and nature of the discussion. This will help you keep track of the details involved with the interactions, such as requests, follow-ups and promises with all parties.