Filing an Insurance Appeal
Disclaimer: This information is provided as information only and not a comprehensive guide to insurance claims or navigating the healthcare system. HESA is unable to provide personal advice or assistance to patients who wish to file an appeal with their health insurance carrier. If you require more information regarding your benefits, please consult your policy contract and contact your carrier for any necessary details. Please use care in determining the relevancy and accuracy of the information found outside of this website as information may be outdated, moved, or changed since this post was written.
While some patients find receiving a diagnosis of a rare and complex condition difficult, it can also be difficult to obtain “experimental” or “off-label” treatments. We’ve gathered some resources for patients who have a diagnosis and a treatment plan but have been denied the prescribed treatment by their health insurance.
In this post, we refer to “you” though we realize you may be assisting a spouse or partner, family member, or friend with the appeal process.
Why are claims denied?
Claims may be denied for a variety of reasons. These reasons are not always clear to patients or those helping navigate healthcare and insurance. Some treatments prescribed for rare conditions, like HE/SREAT, or other forms of autoimmune diseases which are meant to maintain a patient’s health, may be denied due to the high ongoing cost of treatment. If not this reason, it may be that the insurer may feel the treatment does not meet their current requirements as “evidence based”. Thre may other reasons.
Your Explanation of Benefits statement (or EOB) may give you some idea as to why your claim was denied. If you do not understand the reason for the denial, it can’t hurt to ask for an explanation. You may want to gather as much information as possible as to why it may have been denied. Also, ensure that you know where to send a written appeal to the denial letter.
Human Error – Incorrect Patient Identifer, ICD Code, and CPT Code
Sometimes human error may be involved on either side. Before acting on a denied claim, it might be worth speaking to your practitioner’s medical billing and claims department. Did they use the correct patient identifier on your claim?
If not, the insurance company may have denied the claim based on incorrect information. Ensure your the following are correct: spelling of your name, your date of birth, your subscriber number, and group number.
While you’re checking this information, ensure that the correct International Classification of Diseases (ICD) code is being used if you have been diagnosed with HE/SREAT.
As of the writing of this guide, there is no ICD code for Hashimoto’s encephalopathy as it falls under the umbrella term of “other causes of encephalitis and encephalomyelitis“.
Be Mindful that the Code Changed in 2015
The code has changed to G04.81 for “other encephalitis and encephalomyelitis“. According to ICD10data.com, “Other encephalitis and encephalomyelitis. G04.81 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. This is the American ICD-10-CM version of G04.81.” This is now categorized as, “2017 ICD-10-CM Diagnosis Codes, Diseases of the nervous system, Inflammatory diseases of the central nervous system, Encephalitis, myelitis and encephalomyelitis.”
As the website indicates, “Other international versions of ICD-10 G04 may differ.” If you have concerns about the ICD code being used, please consult your physician’s office or other appropriate authority to clarify, if needed.
Another piece of data to check with billing is the use of the correct “Current Procedural Terminology” (CPT) for your treatment. Because patient treatment plans for HE/SREAT may vary, check CMS.gov 2 for a current list of CPT codes which is updated annually.
For some explaination on how CPT codes work, this post on SearchHealthIT is helpful [http://searchhealthit.techtarget.com/definition/Current-Procedural-Terminology-CPT].
Once you have determined that the claim was correctly filed, contact your carrier to discuss your benefits, exclusions, and the reason for the denial. The carrier will be able to supply you with the mailing address or fax number for submitting an appeal in writing (it may also be on your EOB or in your policy contract).
While you may be told you can appeal by phone, appealing in writing ensures you have documentation of your appeal for your records. Keeping a copy of the EOB, denial letter, your appeal letter, and all correspondence can be important if further escalation is needed, for example if a third party is necessary.
It is also important to have a copy of your full policy documents for your records and to refer to if you should have to escalate the claim. Your policy documents should include a section that addresses the appeal process and address your legal right to recovery in the event you should suffer because of denied treatments. Carefully review this information in your contract or with your insurance representative, as insurance companies may include policy exclusions preventing patients from suing for damages caused by delayed or denied treatment.3
A process for disputing a denial must legally be in place, according to healthcare.gov. In the United States, patients have the legal right to information on why their claim was denied and how they can appeal it.
Identify Your Advocates
As you consider how you will appeal, think about what individuals or organizations might be able to assist you in writing your appeal or finding help appealing. Your treating physician may be able to write a letter on your behalf. If you are working with a social worker at a hospital, they may be able to help you locate resources to help you write your appeal. These persons may be hospital staff who help patients complete billing information to help ensure the claim is paid – they want to get paid!
Also, enlist local groups such as charities or religious organizations who may be able to help advocate for or with you during this process. They may be able to help investigate if there are other options for the payment of treatment, such as “Charity Care” programs who help those who do not have access to insurance coverage.
Take advantage of your favorite search engine as well to find local groups who may be willing to help advocate for or with you during this process. There are many local and national disability groups across the United States and they may have many ways to connect with them such as their website, Facebook, or other social media.
Sharing Your Story with Others
Be ready to share your story with others. You might enlist someone to help you write down the details of your HE/SREAT (or autoimmune encephalitis or other rare condition), the process of your diagnosis, the details of your treatment plan, and a brief explanation to others why treatment was denied by insurance. This will help those who can and want to advocate with or for you to understand the situation so that they can effectively help you get the treatment prescribed for you.
Accuracy is very important! If people don’t have accurate information, it can cause confusion and make enlisting help from others very difficult. But don’t feel you have to give “too much” information, keep private details private – the gist of things, as long as it’s accurate, should be enough.
It can be very hard to get others interested in helping you if you don’t share why you need the help in the first place. Simply saying “my treatment has been denied” may not be enough information to get local groups, religious groups, advocacy, or disability groups interested in helping you. Helping others “connect” personally with your story can help them share your situation with others who may be in a position to offer you their assistance.
“Where Can I Find More?”
This is in no way an exhaustive or comprehensive guide to appealing a claim. There are so many resources you can choose from on how to get the help that is most appropriate for your situation. The first step is understanding why you were denied treatment and then choosing the help that best suits your circumstances. We’ve given you some basic details and links to finding more help.
Below are some additional tips and resources for you to explore and make informed choices on how best to move forward from a denial letter from your health insurance carrier.
More Insurance Appeal Tips, Resources, and Disability Advocates
The US Goverment also provides information on HealthCare.gov on the appeals process, found on their page “How to appeal an insurance company decision“.
This is a great printable resource from PatientAdvocate.org about navigating the appeals process with your insurance. [http://www.medicareadvocacy.org/cma-report-medicare-coverage-for-off-label-drug-use/]
The ADA.gov provides a “Guide to Disability Rights” providing helpful general resources for those who are disabled.
The National Disability Rights Network has a list of causes which they advocate for found at http://www.ndrn.org/.
The online version of Forbes Magazine provides some tips in “The 5 Things You Should Know When Your Healthcare Claim Is ‘Denied‘”
Finally, for the top five reasons bills to your health insurance carrier are denied, check out this quick article at www.nerdwallet.com.
1 More information about ICD9 Diagnosis Codes can be found at the website ICD9Data.com, including a list of the current 2014 to 2015 disease symptoms and information.
2 Visit http://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/List_of_Codes.html for a list of current CPT codes for your specific treatment.
3 The options for challenging an insurance company’s decision are limited. Appeals can be slow and cumbersome, if they are available at all, and most patients are barred from suing for damages resulting from denials and delayed treatments.”New York Times “For Denied Claims, a Bit of Help in the Health Law“.
Last edited by Web Team on April 5th, 2017