Appeals — Private Insurance

If your health insurance company won’t pay for the health care you need, you have the right to tell them you disagree. You can ask them to change their decision by making an “appeal.” Appealing your plan’s decision can take several steps.

Step 1: Find the Denial Notice from Your Insurance Company

Your insurance company must send you a written denial that says why they won’t cover your service. If your insurance company denied a service but did not send you a letter, contact them and ask for it.

Be sure to find out when your deadline is to appeal. The deadline is in the denial letter. See below for common reasons why an insurance company won’t cover something.

Health insurance companies who sell plans in Vermont have to publish an annual report each year. These reports show that people who appeal have a very good chance of winning.

Step 2: Contact Your Insurance Company

Look over the “covered benefits” section and the “exclusions” or “non-covered” sections of your health coverage contract to see if the treatment or item you want is listed. If you want more information about coverage for a certain service, you should ask the insurance company for detailed "coverage criteria" for that service.

If you think your insurance company made the wrong decision, call them before filing an appeal. Don’t wait. Make the call only if it will not make you miss your appeal deadline. Sometimes an insurance company will reconsider its decision without a formal appeal. Even if they do not change the decision based on your call, you will learn why they denied coverage. Address their arguments in your appeal.

Blue Cross Blue Shield of Vermont: 1-800-247-2583
MVP: 1-800-348-8515

If you are not satisfied with their response, you can file a formal appeal. Remember that there are timelines for filing an appeal. Your denial letter should tell you how much time you have to appeal the decision.

Step 3: Write an Appeal Letter

In your appeal letter, you need to say why your insurance company should cover the service that it denied. See below for details on what to include in your letter.

You will need these documents for your appeal:

Denial notice or letter from insurance company
Letter(s) of support from the doctor who treated you
Your subscriber member handbook, contract, benefit plan, or summary plan description. If you don’t have these, contact your insurance company so they can send them to you.

Appeal Levels

There are usually three levels of appeal. You move through them step by step until you get the answer you are looking for, or until you have done all three. The letter you get in response to an appeal will tell you what your next step is.

First level appeal (within the insurance company)
Second level appeal (within the insurance company – sometimes this is not necessary)
External appeal (with a third-party – or independent – reviewer)

Need More Help?

Contact us at the Office of the Health Care Advocate (HCA) by filling out this form or calling 1-800-917-7787. Our help is free. If you have a time-sensitive, urgent need, please call us instead of using our form.

Some Reasons Plans Won’t Pay

These are some of the reasons that insurance company’s use when they tell you they won’t pay your bill.

Your plan says the service or item you want is not medically necessary.
You did not get a prior authorization before you got the health care service or item, and your plan says you needed one.
You want to use an out of network doctor or other provider.
You did not get a referral from your doctor.
Your plan says the service or item is not covered by your plan.
Your plan says that the treatment is experimental.
Your claim does not meet timely filing (your provider did not bill soon enough).
Your plan says the claim cannot be paid due to an administrative error (for example, coding issues).
You did not try less costly alternative treatment first.
You have a pre-existing condition. (As of January 2014, insurers are prohibited from denying individuals health insurance coverage due to a pre-existing condition and from charging individuals with pre-existing conditions more, including for coverage of a specific condition.)

You can ask your insurance company to change their decision by making an appeal.

How to Make Your Argument

Once you have the information you need for your appeal, the next step is putting together an argument. Whether you are writing your first level appeal or presenting your second and external appeals over the phone or in person, your arguments should be organized like this:

Introduction

Start with a statement of what you want.
Explain that you are appealing the insurance company’s decision not to cover the service or item you need.
Note the date on the denial notice you received.
Say briefly why you think the insurance company should cover the service or item you need.
Tell the facts that are important to your situation. It is usually best to tell the facts in the order that they happened.

Argument

Say why the service or item should be covered and why the insurance company is wrong not to cover it.
Show parts of the member handbook, contract or other language that support your argument.
Give copies of letters of support from your physician(s) and talk about the letters in your argument.

Be sure to address the reasons the insurance company gave in its denial notice for refusing to cover the service.

Conclusion

Briefly say what you want the insurance company to do and why.

For more information about private insurance plan appeals, visit this Department of Financial Regulation web page about how to appeal a denial of benefits.

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