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You won't know right away if it has happened, but it can be an important question to understand why the claim was denied. Work with a member services representative from the insurance company to confirm that no mistakes were made. “I had already been using my CGM for a few years when my employer changed insurance companies.

My first supply order was rejected. I did not file a formal appeal, but did set up a peer-to-peer call between a plan medical director and my endocrinologist. After that call, my CGM supplies have been covered when I need them.”—Art, 57, Connecticut For starters, it's best to understand why you might have gotten rejected in the first place. This explanation usually comes in a document called an explanation of benefits from your insurer. Here are some common reasons and tips on what to do in each case.

The next section provides more information about the appeals process and some tips on how to help increase the chance that treatment will be approved. THE MEDICATIONS OR TREATMENT REQUIRED (BUT DID NOT HAVE) A REFERRAL OR PRIOR AUTHORIZATION FROM YOUR PHYSICIAN. Work with your doctor through the plan's appeals process to provide proof that the treatment is medically necessary.

Confirm if you needed a referral or prior authorization by reviewing your plan documents or calling a member services representative from your insurance company. Work with your doctor to submit the appropriate referral or prior authorization. Be sure to keep copies of everything you send to the insurance company (including the final appeal letter) and coordinate your appeal efforts with your doctor. THE DOCTOR YOU SEE WAS OUT OF NETWORK. If the health insurance denies your claim, you can start the appeals process, which has three different levels: YOUR COVERAGE HAS EXPIRED OR YOU ARE NO LONGER ENROLLED WITH THE INSURANCE COMPANY THROUGH WHICH THE CLAIM WAS FILED.

Work with your doctor to illustrate that current treatment is improving your Type 1 diabetes through data such as A1c levels and is recommended by clinical guidelines. The National MS Society Toolkit for Clinicians: Second Edition, 2009 (National Multiple Sclerosis Society. Clinician's Toolkit: Second Edition, 2009).

CARE IS SEEN AS EXPERIMENTAL OR INVESTIGATIVE. When you file an appeal, you're asking the insurance company to reconsider its decision to deny coverage for a drug, treatment, or service for your Type 1 diabetes condition. The potential for the appeal to be approved is the most compelling reason to file: More than 50 percent of coverage or reimbursement denial appeals are ultimately successful.1 This percentage could be even higher if you have an employer plan that is self insured.

Despite the promising success rate, appealing an insurance denial can be a daunting task. To help you get started, we've outlined the steps to consider when filing an appeal, key tips to remember, resources to help support this process, and a sample letter. Be prepared to share insurance information (your plan number, member number, and date of birth) in every interaction. Also, have ready the claim number indicated on the document, the date and the doctor who provided the services.

Insurance companies need to locate the claim in question before reviewing it. COMMON REASONS FOR AN INSURANCE DENIAL YOUR CURRENT CARE IS NOT CONSIDERED MEDICALLY NECESSARY OR APPROPRIATE. Check the directory of participating doctors of the plan.

If the doctor you saw was out of network, you will be responsible for some or all of the costs, depending on the plan. If the doctor is in-network for the plan, file an appeal with a physician directory referral. WHAT TO DO ABOUT IT? Contesting a denial of coverage by a health insurance plan is a legal right guaranteed to all insured persons.

All plans, including private policies, employer-sponsored health plans, Medicare, Medicare drug plans, and Medicaid, must provide a process for reconsideration of any adverse coverage determination by the plan. Check with your doctor's office to confirm they have referred you to the correct insurance company for you (sometimes they have outdated insurance information) and may need to be resubmitted. A denial is when the health insurance company notifies you that it will not cover the cost of your medication or treatment.

It can be frustrating and sometimes frightening if you can't fill a prescription, continue treatment, or face the full cost of treatment. The good news is that you have the right to appeal the decision. And while they can be time-consuming to deal with, many health insurance denials can be resolved through the insurance appeals process. In this section, we'll review why you might be denied, some steps you can take to challenge the decision by filing an appeal, and some helpful tips to keep in mind as you navigate the appeal process.

In the next section you will find some common reasons why you might have been rejected and what you can do. ADMINISTRATION ERRORS SUCH AS TYPOGRAPHICAL ERRORS, ERRORS IN THE ORIGINAL STATIONERY, OR DATA RECORDING ERRORS IN THE CLAIM OR INSURANCE POLICY NUMBER. The appeals process has some elements common to all health plans; these elements are described below.

That said, it's important to check the plan's specific process and required information. They can be found in the policy documents or on the plan's website. If you have a plan provided by your employer, you can check with your human resources department or the member handbook provided to you when you signed up. If you have Medicare coverage, please refer to the Medicare & You handbook for the specific process.

Call the insurance company's member services number to find out if coverage has expired or why it has expired, and provide any information needed to confirm coverage if you are still enrolled and paying premiums.