You can win an appeal, but it takes some work. First, read the denial letter. Why was coverage denied? What's the appeals process and timeline?
If it's a billing or claims-processing error, call your medical provider's billing office and ask them to clear things up with the insurer. If a bill is due during your appeal process, consider these suggestions.
If it isn't a billing or claims-processing error, you'll need to appeal to overturn it. Below are some suggestions that might help.
For continued care in an urgent situation
A health plan must provide continued coverage pending the outcome of an appeal. It can't reduce or stop benefits for an ongoing course of treatment without providing you advance notice and an opportunity for review (RCW 48.43.535(9) (leg.wa.gov).
Note: if you lose the appeal, you may be responsible for those medical costs.
Tips for filing your appeal
- Identify your type of insurance coverage and find out if you have a group, individual or government-sponsored plan, and which law your plan follows.
- For Medicare and other plans like TRICARE, Apple Health for Kids, etc. you will need to follow their appeals processes.
- Find out the deadline for an appeal. Where do you send it? These are usually in the denial letter. If not, ask your insurer.
- Determine if you have a non-grandfathered plan or a grandfathered plan and what your appeal options are for your particular plan. If you're not sure which kind of plan you have, call your carrier and ask them.
- Keep a log of every call, email and letter. Here's a printable example (PDF, 641.36 KB) of a contact log.
- Gather your medical records. If you don't have them, ask your medical provider for copies. Here's an example letter. (Word, 32KB)
- Appeal letters should be to the point, timely and specific about the outcome you seek. Here's an example appeal letter (Word, 24KB) and a list of common reasons for a denial and example appeal letters you can use.
- It helps to have a supporting letter from your medical provider. Give them a copy of the reason for denial.
- Don't be afraid to call, especially if someone said they would get back to you and they didn't.
- Send copies of documents, not originals, and send them as certified mail.
What is an independent review organization (IRO)?
If your health plan upholds a claim denial after you completed its appeals process, you can request an external review of your appeal using an independent review organization (IRO). This option should be outlined in the determination letters you receive from your insurer, or you can contact your health plan's customer service line to get more information about asking for an external review. An IRO isn’t affiliated with your insurance company and doesn’t have a financial interest in the outcome of your case.
The IRO can either uphold or overturn the insurance company's position. Once an IRO reviews an appeal, its decision is binding. All IROs in Washington state must register with and be certified by the Office of the Insurance Commissioner.
Our IRO search tool allows you to search IRO decisions. You can modify your search based on a number of factors, including cases involving your insurance company, diagnosis, treatment, outcome or reason for the appeal.
You may want to also file a complaint
Whether or not you file an appeal, you may also want to file a complaint with our office. The appeals and complaint processes are different, and can take place simultaneously without affecting each other. If in doubt, you may want to try both avenues to resolve your issue.