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.
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.