NOTE: for Medicaid-see Medicaid factsheet #4
FACT: Insurance companies depend upon customers not appealing decisions. Only one-third of consumers file appeals. 50% of the time, the decision is reversed on the first appeal. Here are the steps to follow from most basic to most extreme, as needed.
1. Call your insurance company to appeal. Be prepared to follow-up in 2-3 weeks if you don’t get a new explanation of benefits.
If that doesn’t work…
2. Write an appeal letter. Include a copy of the claim and denial. Attach a doctor’s note if necessary. Send it certified mail, return receipt requested.
If that doesn’t work…
3. Many times, your employee benefits department will assist you with a difficult claim.
If that doesn’t work…
4. Send an additional appeal, including additional documentation as to the medical necessity of the service. This time, copy the NJ Commissioner of Insurance. Although many “self-funded or self-insured” plans aren’t subject to state regulations (due to the federal ERISA {Employee Retirement Income Security Act}), these are the same insurance companies that compete for the Medicaid managed care and other state contracts, so they don’t want to look bad to the Commissioner.
If that doesn’t work…
5. Contact an advocacy organization such as the Community Health Law Project.