HEALTH RIGHTS HOTLINE Independent Assistance For Health Care Consumers

Some appeals are simple and require only a statement of the facts and the basic reasons why you believe the condition or treatment should be covered by the health plan.   For others, however, more information is necessary.   You may want to consider the range of information listed below, such as medical literature, treatment guidelines, expert opinion, and more.

While you want to find information that supports your appeal, don't be afraid to include material that disagrees with your position or compares both sides of the issue.   Experts sometimes have different opinions as to the most appropriate ways to care for a patient.   Understanding all of the options will help you present your best case.   It will also help you know you are on the right track for getting the best care.

Clinical Information

Clinical information reviews health conditions and specific treatments.   It is based on observing you or patients in similar situations.   This kind of information may strengthen your appeal.   Be sure to show how the treatment you want is the best choice, with the fewest problems or complications.

Doctors' Opinions

The opinions of doctors and specialist and evaluations by doctors who have treated you or reviewed your records are relevant to your case.   Opinions of doctors who specialize in treating similar conditions are relevant also.   The opinions of doctors who specialize in treating your condition will be given more weight than are those of non-specialists. You can get a letter from your doctor(s) or you may find this information in your medical records.

ACTION TIP Ask the doctor(s) who have treated you or who have experience treating your condition for a letter to support your case.

Medical Journal Articles

Studies of specific conditions or treatments may recommend the kind of treatment you are requesting in your appeal.   They are usually written in medical terms and you may need to ask for help to understand them.   It may be harder to find articles on new technologies or treatments due to delays between the research and publication.

ACTION TIP Look for articles in medical journals that are well respected by medical professionals.   A librarian or your doctor can advise you on this.

Treatment Studies

Studies that measure the results of the type of treatment you are seeking may be helpful.   When a health plan considers a request for a treatment that is new or requires the latest technology, "randomized" or "controlled" studies are often important to the decision of whether to cover the treatment.   "Randomized" trials compare groups of people who receive a specific treatment to other groups who do not.   "Observational" studies, where no comparison can be made, are sometimes less convincing sources of information.

ACTION TIP Ask for help evaluating the results of treatment studies before including them in your appeal.

Medical Guidelines

Specific medical specialty organizations and some other groups sometimes develop "consensus statements" or "treatment guidelines" that may provide you with information to support your appeal. Government agencies also conduct medical research and recommend approval for specific medications and treatment.

ACTION TIP Your health plan may have guidelines to determine how a particular condition can be most effectively treated. Ask your doctor, medical group, or health plan for a copy of any treatment guidelines that relate to your condition.

The Cost of Care

While your health plan's primary concern should be your health, the total cost of caring for members is frequently a consideration. Total costs generally include:

• the costs of treatment;
• the long-term costs of follow-up care; and
• the potential costs of follow-up care if there are complications.

Your appeal could include showing how providing what appears to be an expensive treatment in the short-term, may cost less over time and be better financially for the plan. You might also show that not providing care or limiting you to a less-expensive treatment, may not save them money in the future.

ACTION TIP Look for medical articles and/or talk to doctors that can show how the treatment you want may cost less over time than other treatments and include that information in your appeal.

Legal Information

State and federal law may require your health plan to provide certain services. For example, in California, certain preventive measures such as mammograms or screening for prostate cancer are now the law.

ACTION TIP Consult the Health Rights Hotline Action Guide "Resources to Help You Resolve Your Health Care Problems" for agencies that can help you understand the regulations and legal requirements that your health plan must follow.

CALL THE HEALTH RIGHTS HOTLINE

The Health Rights Hotline is a totally independent, free service that provides information and assistance about your rights as a health care consumer. Experienced counselors answer questions and help you in the appeal process. If you need assistance, give us a call.