Presented by: Maryland Family Access Initiative. Maryland. Child and Human Development

Transcription

1 Appealing Insurance Denials Presented by: Maryland Family Access Initiative A Partnership between Parents Place of Maryland and Georgetown University Center for Child and Human Development MFAI is funded by Grant No. 1 H93 MC from the Division of Services for Children with Special Health Care Needs, HRSA, U.S. DHHS

2 About Maryland Family Access Initiative A project funded by the federal Maternal and Child Health Bureau to assist families to access comprehensive services from managed care organizations which meet all needs of their children with SHCN, and to ensure their enrollment in the plan best suited to their individual needs.

3 About Parents Place of Maryland How do we help? Education Information Technical assistance Supportive activities

4 About Georgetown University Center for Child and Human Development The Center provides research, training, policy analysis and development, and technical assistance.

5 Introduction Periodically all plans deny payment for services for a variety of reasons Denials of payment can and should Denials of payment can and should be appealed

6 Agenda After this workshop, you will be able to: Identify instances in which an appeal is appropriate Understand what an Explanation of Benefits is, and how to read them Identify steps to be taken prior to filing a formal appeal of a rejected claim List the information that needs to be gathered before an appeal can be filed Know which State and Consumer agencies are available if an appeal fails

7 Overview Many factors go into insurance approvals and denials Never underestimate that YOU are your child s foremost care provider! HMO PCP PP O Child POS CPT DS M- IV EO B ICD-9

8 Vocabulary HMO, PPO, POS EOB Letter of Medical Necessity Internal Review External Review

9 Sometimes Denials are Appropriate. Know your plan!!

10

11 Look before you leap Confirm coverage before getting services.

12 Prior Authorization Some services (often mental health services) require pre-approval. Know which ones require prior authorization and who has to obtain it.

13 What does medical necessity mean? Each plan has different definition Often no exact guidelines Your doctor can help show medical necessity

14 How will I know if my claim has been denied? Explanation of benefits will indicate no payment and give reason. Bill from doctor, hospital or lab that shows no payment.

15

16 Explanation of Benefits Document generated dby your health lhinsurance provider COMAR B The summary shall identify the provider by name and shall state the: (1) Date of the service; (2) Amount claimed; (3) Amount which was paid or is payable by the insurer on claims processed during the year; and (4) Balance to be paid by the covered individual, if the balance is determinable from the claim forms submitted.

17

18 Know Your Coverage Get a copy of the EOB denying the claim, and make sure you understand why the claim was denied d Review your benefits manual to see what it says about the service that was denied

19 We all make mistakes. Many denials are simply clerical errors. The first step after getting a denial is to call the plan and have them check for an error.

20 DON T BE STOPPED BY DENIALS!

21 If your health plan refuses to pay for treatment, you can and should consider appealing if: The treatment isn t a covered benefit, but you think the health plan should make an exception for you, or You have support from your physician that the treatment is medically necessary, or The treatment is deemed by the insurance company to be experimental or investigational. Appealing Health Insurance Denials by Heidi Frey Appealing Health Insurance Denials by Heidi Frey Martindale-Hubbell Lawyers.com

22

23 The Paper Trail Keep all of the documentation about this claim together, for quick reference. When you make a phone call, use a phone call log to document the conversation.

24 Be prepared to spend a lot of time on the phone..

25 Document, Document, Document! Document all conversations! Even if you just leave a message for someone to return your call, document it!

26 Call the Provider Call the provider to verify that they received the rejection. Ask them if they are going to do anything further with the claim (resubmit it with supporting records, etc.)

27 Call your Insurance Carrier ( the internal review ) REMEMBER: NEVER ACCEPT NO AS AN ANSWER FROM SOMEONE WHO CAN T SAY YES

28 Remember to STAY POSITIVE!

29 !!!RED PEN MOMENT!!! Some health insurance carriers will say, that s the package that your employer bought. THIS IS NOT ALWAYS TRUE!!!

30 Don t call us, we ll call you. NOT!

31 Get It On Paper -Appeals must be in writing -Check your plan s process

32 Part 1: Identification The Letter

33 123 Elm Street Hometown, Maryland January 2, 2004 CareFirst BlueCross BlueShield th Street, Southwest Washington, D.C ATTENTION: CLAIM APPEAL DIVISION Re: Subscriber: John Doe Member Identification Number: Claim Number: Patient s t s Name: Sally Doe Relationship to Subscriber: Child Date of Service: 02/27/03 Provider: Dee Best-Pediatrician, M.D.

34 The Letter Part 2: Purpose

35 Gentlemen: The above referenced claim was denied due to (state the reason use the wording from the EOB).

36 The Letter Part 3: Diagnosis

37 My child, Sally, has been diagnosed with migraine headaches. These headaches have recently been occurring more frequently, and with greater intensity. She is starting to miss time from school because of them, and due of the nature of her migraine headaches is unable to keep up with class work and homework assignments. Accordingly, her physician and I are concerned that there may be a biological cause for these headaches, such as a brain tumor.

38 The Letter Part 4: Reasons

39 While the CT Scan that was performed on Sally on 11/30/02 showed no abnormalities, Sally s migraines have increased in frequency and intensity since that time. Dr. Best-Pediatrician feels that an MRI would be a more accurate diagnostic tool to rule out biological reasons for her migraines. While I realize that a CT Scan is the normal course of treatment to rule out tumors in migraine sufferers, Dr. Best-Pediatrician feels it is medically necessary to have an MRI performed to further rule out tumors and other biological causes of Sally s migraines. I am enclosing a letter from her indicating its medical necessity.

40 The Letter Part 5: Documentation

41 I am also enclosing a copy of Sally s medical records from Dr. Best-Pediatrician. These show that she has been seen frequently in the last 4 months for migraine headaches. h

42 The Letter Part 6: The Action

43 As time is of the essence in this matter, I would appreciate your reviewing this appeal as soon as possible. Should you require any additional information, please contact either myself or Dr. Best-Pediatrician immediately. Sally has not had the MRI performed as of this date, as we are awaiting approval for coverage of this assessment from your company. I ask that you reply to this request by January 9, Respectfully, John Doe Enclosures: as stated. cc: Dr. De Best-Pediatrician Suzie Thomas, Human Resources Josie Shannon, Human Resources

44 Letter of Medical Necessity The supporting documentation you send with your letter of appeal should include a Letter of Medical Necessity.

45 Internal Review At this point, your plan will conduct an internal review Maryland law provides: 24 hour review if there s an emergency 30 day review if service hasn t been provided 45 day review if service has been provided

46 !EMERGENCY! If the appeal involves an urgent need for care, make that clear to the health plan so that they can expedite your appeal.

47 What if it doesn t work?

48 External Appeals Maryland law requires that t you exhaust your health plan s internal grievance process before you can ask the Maryland Insurance Administration to review the matter. How to get more information: Maryland Insurance Information 800/ / TTY state us Attorney General, Health Education and Advocacy Unit, 877/

49 Exceptions to The Rule -ERISA plans -Medicaid -Federal plans

50 Summary What is an EOB? What is an internal appeal referred to as? What is an external appeal? What are exceptions to the appeal rule?

51 Remember: Keep good records! Get denials of coverage and reasons for them IN WRITING! Become familiar with your health Become familiar with your health plan policy or membership booklet.

52 Where to Get More Information Resource for writing letters: and type in stranger in their search engine Internet: type in health insurance appeals in a search engine -- you can also type in the specific service being denied

53 Thanks!