Appealing Health Insurance Denials
If you receive a claim denial and do not agree with the decision, consider appealing the denial. Go back and review the patient's insurance policy for coverage information. The explanation of benefits (EOB) letter from the health plan is the key to payment or denial status. If the coverage language supports payment, write an appeal letter describing the disorder and its medical nature, and reference the coverage policy paragraph that shows how your treatment fits coverage criteria.
One important piece to pay attention to from the start is whether or not the denial is due to a coverage decision (e.g., medical necessity, prior authorization, visit limit reached) or a plan exclusion. If the denial is related to a plan exclusion, the appeals process would not apply, and the patient should consult their plan sponsor or employer when applicable.
General Appeals Templates
- Continuation of medically necessary care beyond visit limitations [PDF]
- Lack of prior authorization obtained [PDF]
- Medical necessity [PDF]
- Request for a peer-to-peer review [PDF]
Audiology Related
- Hearing aid for a child [PDF]
Speech-Language Pathology Related
The health plan may conduct an internal review of the denial. If all levels of appeal are exhausted, and you still believe your treatment meets coverage definitions, consider taking the case to the external claim review level. Currently, 46 states have an external review process (go to the Kaiser Family Foundation's website to see each state's procedure and contact points).
Questions?
Contact reimbursement@asha.org.
