HEALTH RIGHTS HOTLINE Independent Assistance For Health Care Consumers

If you are dissatisfied with a decision made by your health plan, medical group or doctor and you want to request a different decision, there are steps you can take. The information in this action guide is designed to help you figure out what you want, how to prepare an appeal, and identify additional resources available to help you.

The first steps in resolving a problem are always to talk with your doctor, your medical group and health plan. If you get your health coverage through your employer or if you buy it yourself, your human resource department or the agent that sold you the policy may be able to help.

MAKING YOUR CASE - A Summary

Understand The Problem

• Know your health plan benefits, exclusions and limitations
• Know who denied your care or coverage and why it was denied;

Prepare Your Appeal

• Write a brief statement
• Support your statement with facts
• Your symptoms, treatment history and doctor's recommendations
• A letter from your doctor
• Your health plan documents
• Additional information such as articles or expert opinion
• Consider legal advice

KNOW YOUR HEALTH PLAN BENEFITS AND EXCLUSIONS & LIMITATIONS

Your health plan benefits, and exclusions and limitations, will be described in your "Evidence of Coverage" or "Summary Plan Description."

ACTION TIP Before you decide to file an appeal, you should check these documents to determine

• The general terms of your coverage - what the plan documents say is covered; and
• The specific exclusions and limitations of coverage - what is specifically not covered.

WHY APPEALS ARE FILED

• Your doctor, medical group, or health plan states that the treatment you need is not covered under your health plan benefits.
• A treatment you have requested, that you think is necessary and is covered, has been denied because it is considered to be experimental or not medically necessary.
• A treatment or medication that has been authorized is not what you believe to be the best course of care.
• Your health plan or medical group is denying payment for a treatment you have already received.

KNOW WHO HAS DENIED YOUR CARE OR COVERAGE

If the denial is from your doctor, talking it over with him or her may make a difference. Perhaps a second opinion or choosing another doctor may help. It is important that you understand the reason for the denial. If you don't understand why what you want has been denied, ask your doctor to explain it in terms you can understand.

ACTION TIP Talk to your doctor first. Make sure your doctor understands your symptoms and concerns. Make sure you understand what your doctor recommends.

If the denial is from your medical group or health plan, contact either your medical group's patient assistance or health plan's customer service departments, whichever one made the denial decision. Ask the representative to explain the reason for the denial, and ask for the reason in writing.

KNOW WHY THE CARE OR COVERAGE HAS BEEN DENIED

The reason why the care or treatment has been denied is important. Be sure to get the reason for the denial in writing. If your medical group or health plan says that the care is not covered, you will need to explain why you disagree. If you agree that the treatment you want is not a covered benefit, you may want to talk to your employer about changing the benefit coverage.

ACTION TIP Understand who has denied the care. Be sure to get the reason for the denial in writing. Ask your doctor, the medical group your doctor is in, or the health plan for a full explanation.

If the reason for the denial is that the care is not "medically necessary", or if another treatment is suggested, you will need to explain why the treatment you seek is the most appropriate one for your condition. Doing so may require you to do some medical research to learn more about your condition and treatment options. (See the Health Rights Hotline Action Guide on "Learning More About Your Health Condition").

PREPARING THE APPEAL

Once you understand what your plan will cover, and you believe your condition or requested treatment is not excluded from coverage, and you believe that the treatment sought is the most appropriate treatment for you, then you are ready to begin to prepare your appeal.

You will probably need information from a variety of sources. Every situation is unique, and you need to make a strong case for what you want.

ACTION TIP Make sure you are familiar with your plan's requirements for filing an appeal. File your appeal within the time limits set by your plan. Check the denial letter, your health plan documents (the EOC or SPD) or call your health plan's customer service department for information about submitting an appeal.

WRITE A BRIEF STATEMENT

Start by writing a brief statement of what you are requesting from your medical group or health plan. Be specific and write down:

• What action you want your health plan to take.
• Each step you have already taken including the dates and the names and titles of the people you have talked to about the treatment and your condition.

ACTION TIP If you have an urgent need , ask for an "expedited" decision. In urgent situations health plans must respond quickly, usually within 72 hours after receiving your appeal.

SUPPORT IT WITH FACTS

The facts of your situation should support your request. As you prepare your appeal, consider including:

• The symptoms or health problems you have experienced and for how long.
• Your treatment history.
• Your doctor's recommendations, and the care, if any, that your doctor or medical group is offering you.
• If your health condition has improved with any treatment or if it is likely to get worse without the care you want.
• The contacts and conversations you have had with your doctor, medical group, or health plan related to the denial and your medical condition. If you have anything in writing, from your doctor, medical group, or health plan.

You may also want to ask your doctor to write a letter stating the reasons why you need the treatment or service.

GET YOUR MEDICAL RECORDS

Reviewing your medical records can inform you about the reason why the decision was made and give you specific facts to support your appeal. Your medical records may include tests, x-rays, charts, and letters. You may have to pay for copies of your records. Doctors, hospitals and other providers are allowed to charge a "reasonable" cost for copies of medical records. You also may need to:

• Find out the specific procedure for getting your medical records from each doctor or hospital. (The law requires that the records be provided to you within 15 days of your written request).
• Have all of your records from non-plan doctors sent to your doctor and your plan. (Often if your doctor requests your medical records, they are provided at no charge).

Be sure to keep a copy of all your medical records for yourself.

ACTION TIP Call your doctor's office and find out how to request your medical records. There probably will be forms for you to sign and you may have to pay a fee. Also ask how long it will take to copy them and whether you can pick them up or must receive them by mail.

QUOTE DIRECTLY FROM YOUR HEALTH PLAN DOCUMENTS

When preparing your appeal use the official benefit or coverage terms from your Evidence of Coverage (EOC) or Summary Plan Description (SPD).

• Always refer to the document, the section number(s), and the page(s) where you found the quote(s) you included from your health plan
• State why you believe the treatment you seek is "medically necessary" or, if it applies, is not an "experimental treatment."

INCLUDE ADDITIONAL RESEARCH INFORMATION

You may need to find additional technical or legal information which supports your appeal. This information may come from medical journal articles, treatment guidelines, and opinions of doctors and specialists. (See the Health Rights Hotline Action Guide "Information To Support Your Appeal.")

ACTION TIP Be sure to include in your appeal packet any supporting information you find, stating the source, the date, the page numbers, and any other details you believe are important to your case.

PUTTING IT ALL TOGETHER

• Make sure that you know the exact person, department, and address to whom your appeal should be sent. The address should be listed in your EOC or SPD. If you are concerned about meeting a specific deadline, send your packet registered mail, return receipt requested. This will give you proof that you filed on time.
• Keep a copy of your letter and all of the information you forward for the appeal. If you send copies of medical records and letters from your plan or doctor(s) be sure to keep the originals.
• Understand how long the plan has to respond to your appeal. If you are concerned about a delay, call the plan and check on the progress of your appeal. Be persistent.

And always, ask for help from your doctor, medical group, or health plan if you are unsure of what to do or if you are having trouble finding and putting together the necessary information.

CONSIDER GETTING LEGAL ADVICE

If you feel you need professional help in making an appeal or if you believe that your case could become a legal matter, you might consider contacting an attorney.

CALL THE HEALTH RIGHTS HOTLINE

Health care coverage can be complicated, but you do have rights. The HEALTH RIGHTS HOTLINE is here to assist you. The HEALTH RIGHTS HOTLINE is a totally independent, free service that provides information and assistance about your rights as a health care consumer. Trained counselors will answer your questions, help you to resolve issues with your medical group or health plan, and assist you in your appeals process. If you need assistance, give us a call.