Show Image source: howcast.com Whenever you deal with an insurance company, keep copies of all the paperwork. Make a copy of your submitted claim and all supporting documents. This will ease the process of filing an appeal in the event that your claim is denied. If the insurance company rejects the claim, the first thing to look for is the explanation of the denial. Typically, this will be included in the letter of denial. If you cannot locate an explanation, call your insurance company and ask them to send you a writtenexplanation of the denied claim. You should also request that they send you the name, medical license number, and state issuing the medical license of the person who denied your claim. Request the insurance company’s instructions for filing an internal appeal.  Image source: glamour.com Thoroughly review the explanation of the denial. There are a few common reasons why an insurance claim for speech therapy may be denied. The insurance company may not cover all services or they may only cover a certain number of visits, for example. If the explanation for denial does not make sense to you, make an appointment with your employer’s human resources department to discuss your policy. Let your child’s speech therapist know that your insurance company denied the claim. Ask her to write a letter in support of the speech therapy, stating explicitly why your child requires treatment. Obtain a letter of referral to a speech therapist from your child’s pediatrician. Create a Letter of AppealWrite a letter of appeal in accordance with the insurance company’s instructions for an internal appeal. Include all the relevant information, such as your child’s name, the health plan identification number, the dates of service, and a concise explanation of why the claim should not have been denied. Include all supporting documents, such as a copied page from your insurance policy that proves that the treatment should have been covered. Image source: wlshelp.com Send the appeal letter to the appropriate department in your insurance company. If you do not know the proper department, call the insurance company and ask for this information. Mail the appeal letter via certified mail, return receipt requested (always keep the return receipt!). Follow-up with your Insurance CompanyContact the insurance company regularly to check on the status of your appeal. Every time you call the insurance company, keep a record of it. Write down the full name, title, and department of the representative you contacted, as well as a brief synopsis of the conversation. If your appeal is denied or the insurance company fails to address it in a timely manner, contact your state’s department of insurance. The National Association of Insurance Commissioners can tell you which department to contact in your state. If your state does not have a specific office for insurance cases, contact your insurance company to request an independent review. Only resort to this option if you have already exhausted all possible internal appeals within the insurance company; otherwise, your request will simply be denied. Financial Resources How Did We Get Here?Example 1 Your child has autism. Your child also gets sick, a lot. You take him to the doctor, again, to see what they can do to get him healthier. The doctor orders blood work that shows your child has a very weak immune system and multiple food allergies. The doctor refers you to an immunologist but codes the superbill with 299.0 (autism). The insurance company denies the specialist visit and all treatment because autism in (in their eyes) untreatable. This is an example of denial due to improper coding. Solution: Call the doctor back and ask that the superbill be recoded to reflect WHY he needs the immunologist – due to immune deficiencies and allergies and REMOVE all reference to autism, as it’s not relevant to this case. This is one of the quickest routes to medical denials you will find. Make sure you never leave the doctor’s office with a superbill that says “autism” unless you are treating with psychotropic drugs. Those are the only approved “treatments” for autism according to the insurance industry. Example 2 Your child has autism. Your child also lost the ability to speak when he regressed into autism. Your doctor writes a script for Speech therapy. Your insurance company says they don’t cover speech for autism. Period. Solution: Why did your child stop speaking? Did he (like most kids I know) have recurrent ear infections? If so, bill it under that. Does he have verbal apraxia? If so, bill it under that, and so on. Example 3 Your child has autism and your insurance company tells you they cover 60 visits a year of speech therapy. Your pediatrician and speech therapist recommend therapy 5 days a week (intense therapy while the child is very young will likely reap bigger dividends long term) but that would mean 260 visits in the year, not 60. Solution: Appeal! Ask your insurance company what their appeal procedure is and if there are any special forms they want you to use. Get your doctor to write a letter of medical necessity for the extra therapy sessions. Ask the speech therapist to write a letter of medical necessity for the extra therapy sessions. Write a cover letter that explains why you need it, and don’t be afraid to pull at their heartstrings! You are passionate about your child getting better, let it show! Example 4 All of the in-network providers reject you – they aren’t taking new patients, don’t treat pediatrics, won’t treat a child with autism or if the insurance company doesn’t have anyone contracted to provide a particular therapy. Solution: Appeal! You can appeal for them to let you go to an out-of-network provider - but they must reimburse you at in-network rates and maximums. They can create a contract-for-one if need be. Example 5 The insurance company tells you that your school should provide it so go to them. Solution: This is illegal. Appeal. A letter of medical necessity should do the job. What To Do When You Get a Denial of Coverage So things are swimming along and your EOB (Explanation of Benefits) comes that says DENIED! Here’s what you do. The best way to fight a denial is to never get one. To that end, take the steps on How to Start Working with Your Insurance Company. Knowledge is power and if you can head off a mistake by knowing what is allowed and what isn’t, it will save you in the long run.
State Department of Insurance Appeal Resources Consumer Reports Consumers Union National Association of Insurance Commissioners Directory of Insurance Regulators by State Consumer Action - Federal Consumer Information Center Some Tips About State Laws
Understanding the State Insurance Process
How do I write a letter of appeal for a denied claim?Things to Include in Your Appeal Letter. Patient name, policy number, and policy holder name.. Accurate contact information for patient and policy holder.. Date of denial letter, specifics on what was denied, and cited reason for denial.. Doctor or medical provider's name and contact information.. What is appeal letter in medical billing?The medical billing appeals process is the process used by a healthcare provider if the payer (insurance company)or the patient disagrees with any item or service provided and withholds reimbursement payment. Some of the reasons for claim denial include: The patient is not enrolled in the plan or with the payer.
How do I write a letter to Health Insurance Claim?Sir, I am writing this letter to claim my health insurance as I am suffering from heart disease (Actual cause). Doctors at (Hospital name) have informed me about the surgery that I have to undergo next week which costs approximately (amount of money) including medicine charges.
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Insurance appeal letter for speech therapy sample
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