Medical Appeals

Medical Appeals

Helping Those You Serve Navigate Through Medical Insurance Denials

• Get members insured.   See the Medical Pages under the Storehouse of Specialist on the mission website.  https://icp.churchofjesuschrist.org
   
• If required BEFORE a procedure get pre-authorization from the insurance company.  Most times the physician’s office will submit this, if not, call or write to get pre-authorization.  Start early, this can take up to 14 days.  If health requires a procedure to be done quickly ask for a “Fast Coverage Decision”.
   
• If there are financial concerns that paying will/could be a problem have the Financial Assistance form filled out, with required documents, before going to the hospital. (a link for IHC and UofU Healthcare is on the web page).
   
• Once the procedure is done if you get a denial to pay benefits from the insurance company you have the right to file an appeal.   Your insurer must notify you in writing and explain why:
  • Within 15 days if you’re seeking prior authorization for a treatment
  • Within 30 days for medical services already received
  • Within 72 hours for urgent care cases
• File your claim in a timely manner. Keep the forms or letters showing what payment or benefits were denied.   To file an internal appeal, you need to:
  • Complete all forms required by your health insurer. Or you can write or call your insurer with your name, claim number, and health insurance ID number.
  • Submit any additional information that you want the insurer to consider, such as a letter from the doctor.
• If you have someone appealing the appeal other than the patient or physician, you must include an Appointment of Representative form authorizing this person to represent you.
   
• Let your provider know that you are appealing the denial of coverage.  Stay in communication with your provider.  There is not a pause in the time for the bill to be paid because of an appeal.  Keep the provider “in the loop”.  Do not ignore letters and phone calls from the provider. 
   
• Ask the provider, most likely through the Financial Assistance office, to not send your bill to a collection agency as you are appealing.  They will be patient if you keep providing them with information on the appeal process and might be able to help with the insurance company.
   
• Get and Keep copies/records of everything.  Papers from the provider, the insurance claim denial, papers you send the insurance company.  Note phone calls, dates, and the person you spoke with.
   
• Keep track of dates and keep contacting the insurance company if they go over the days they are given in the appeal process.
   
• In the event you are denied again, you can submit for an external appeal.  Be steadfast: The appeals process can take some time.  Your doctor will need to advocate on your behalf. They can have a peer-to-peer conversation with the medical reviewer for your case or write an appeal letter explaining what they are treating you for, your medical history, why the treatment is recommended and any information or evidence that would support coverage.
   
• As you’re going through the appeals process, request copies of all the insurance company’s paperwork, such as their claim diary and the forms that were submitted to the company. It could be something as simple as a typo or misclassification that resulted in your claim being denied.
   
• If you feel you are not being treated right by your insurance company you can call the UTAH HEALTH INSURANCE CONSUMER SERVICE.  They help with consumer concerns, complaints, and independent review.  801-907-9280.