Help for Your Legal Problem

Appealing a Decision About Your Coverage

If your health insurance company won’t pay for the health care you need, you have the right to tell them you disagree. Here’s a link to a list of common reasons why an insurance company won’t cover something.

You can ask them to change their decision by making an “appeal.” In Vermont, people who appeal have a good chance of winning. Here are the steps for making an appeal:

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 or you cannot find it, contact them and ask for it.

Be sure to find out when your deadline is to appeal. The deadline is in the denial letter. If you do not file an appeal within the deadline, the insurance company does not have to reconsider whether you are entitled to coverage.

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 they will reconsider their 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. Read more detailed information about appeals on our website to get ready. 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 our web page about appeal letters and arguments 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 insurance company’s list of covered services. This can be found in 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 coverage for the services you want, or until you have done all three. The letter you get in response to each step 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.