HEALTH RIGHTS HOTLINE Independent Assistance For Health Care Consumers

Health Rights Hotline Sample Letter

Appeal of a Denial of Services as "Not a Covered Benefit"

If you are denied a health care service, treatment or procedure that you believe is medically necessary and covered by your medical group or health plan, talk to your doctor, medical group, and health plan. If you cannot resolve the problem over the telephone, you might need to write a letter appealing the denial. This letter provides a basic format for appealing services denied because your medical group or health plan claims that the services are not covered under your health plan contract, and you disagree. You can use this letter if your medical group or health plan has denied authorization for a service, treatment, or procedure. Be sure to add your own facts to this letter.

Here are some tips for using this letter:

• All of the language suggested may not apply to you. Use only the parts of the letter that are appropriate based on your facts.
• Places where you can insert your information are identified by brackets ("[ ]"), and the description of the information to add is underlined. You should delete the brackets and the sample description, and fill in your own information, where it applies.
• The letter includes advice to you that is in parenthesis ("{ }"), with the text of the advice in italics. You should delete these sections from your letter.
• The sample letter is addressed to the "Customer Service Department." Your health plan may use a different name for the department that receives complaints, grievances and appeals from its members. Check your health plan documents or member handbook [usually called the Evidence of Coverage (EOC) or Summary Plan Description (SPD)], or call your medical group or health plan, to find out to whom your letter should be sent.
• Check your health plan documents or member handbook (EOC or SPD) for your plan's requirements for filing a complaint, grievance or appeal. You should follow your health plan's procedures, including any time limits, when you file a complaint, grievance or appeal.
• There are different laws that apply to different types of health care coverage. The laws that apply in your circumstances may depend on where you live, what type of health plan you have, and how you get your coverage. Check your EOC for information about the agency that regulates your health plan, then check with the agency to see what set of laws apply to your case. Remember, it is not necessary to quote the law in your letter, but doing so may help make your case stronger.

For example, the legal standards that relate to denials of care for Californians in Health Maintenance Organizations (HMOs) are found in California Health & Safety Code §§1363.5, 1368, 1368.01, 1368.02, 1368.03, 1368.1. These sections of the law apply only to licensed California health plans regulated by the California Department of Corporations.

• If your need for treatment is urgent, you may have special rights to have your case decided quickly. Contact your health plan or check your plan member handbook for information on "expedited review" or "urgent appeals." The section of the sample letter in UNDERLINED BOLD CAPITALIZED ITALICS is a sample of language that can be used in cases involving an immediate and serious threat to health.
• Attachments - You should attach to your letter copies of any information that helps explain your case. Support from your doctor is usually very important if you are requesting your health plan or medical group to cover a certain procedure or treatment. See the Health Right's Hotline's "How to Appeal a Health Plan or Medical Group Decision" and "Learning About Your Medical Condition" for more information on what you may want to attach to your letter. At the end of the letter are examples of the sort of attachments you might want to include. In some cases, a letter may have no attachments; in other cases, there may be many.
• Sending Copies - You should consider sending copies of your letter to others who may be helpful in resolving your problem. Suggestions for who you might want to send copies to are listed at the end of the letter. You should decide who might be helpful in resolving, and who you would like to know about, your problem. It is not likely to be appropriate for you to send copies of your letter to all who are listed on the sample letter under the "cc."

   

  

  Health Rights Hotline
  Sample Appeal Letter for Services Denied as "Not a Covered Benefit"
  (see tips for using this letter)

  [Date]
  
  [Your Medical Group or Health Plan]
  Customer Service Department
  [address]

  
  

  RE:	Appeal for [your name] OR URGENT APPEAL for [your name]
  	Subscriber #[your number]

  Dear Customer Service Department: 

  I am writing to appeal [name of medical group OR health plan]'s decision to deny authorization for [name of service, procedure or treatment sought] for me. The [medical group OR health plan] has denied coverage for [name of service, procedure OR treatment], as not a covered benefit under my plan. I believe [name of service, procedure OR treatment sought] is medically necessary to [treat or diagnose OR address] my medical condition and is a covered plan benefit. [Name of medical group OR health plan] should approve [name of service, procedure OR treatment] in my case.

  FAILURE TO PROVIDE IMMEDIATE TREATMENT FOR MY CONDITION INVOLVES AN IMMINENT AND SERIOUS THREAT TO MY HEALTH. I AM, THEREFORE, REQUESTING AN EXPEDITED REVIEW OF MY APPEAL. PLEASE NOTIFY ME OF YOUR DECISION AS SOON AS POSSIBLE, AND NO LATER THAN THREE DAYS [or time specified in your evidence of coverage] FROM THE DATE OF MY REQUEST.

  [Name of health plan] covers medically necessary services that are not specifically excluded, in addition to services specifically included under the plan terms. {If the service or treatment you are seeking is specifically included under your coverage, say so here. [Name of health plan] specifically includes coverage for [name of service, procedure OR treatment]. See [page #] of the [Evidence of Coverage OR Summary Plan Description]. The following language is a sample for use if the service or treatment you are seeking is not specifically covered.} [Name of health plan] definition of medical necessity is found on page [page #] of my [Evidence of Coverage OR Summary Plan Description]. Medical necessity is defined as:

  [insert plan definition of medical necessity from your member handbook]

  As explained below, [name of service, procedure OR treatment sought], for addressing my condition, falls within this definition. The plan excludes treatments and procedures listed on page [page #] of my [Evidence of Coverage OR Summary Plan Description]. [Name of service, procedure OR treatment sought] is not listed as an exclusion or limitation under my health plan coverage.

  [Name of service, procedure OR treatment sought] is recommended for my condition by [doctor OR specialist supporting your request], and is considered medically necessary to [treat, monitor, OR diagnose] my condition. Further, [the service, treatment OR procedure] is within the standards of good clinical practice. {If you are in a state that has "mandated benefit laws," or laws that require plans to provide certain coverage, it can be helpful to refer to provisions that mandate coverage for the treatment or service you are seeking. The following language may be appropriate if there are "mandated benefits laws" that apply to your situation. The [medical group OR health plan]'s failure to provide [name of service, procedure OR treatment sought] also violates [California OR other] law which requires [applicable legal requirement]. (See Cal. Health & Safety Code ' [code section number].)}

  {In one or more paragraphs, describe your condition. Keep your description brief but sufficiently detailed to include a chronology of your symptoms, and any tests and treatments you have undergone. The amount of detail you use will depend upon your specific situation. Following is a sample paragraph.}  

  I have [name of condition OR "an undiagnosed condition"] and it affects my ability to conduct activities of daily living. I have previously received [types of other treatments you have tried AND/OR diagnostic tests you have undergone, if any] to [address AND/OR diagnose] my condition. However, my health problems have not been resolved. Without [name of procedure or treatment], I will continue to experience [symptoms/problems]. If left [untreated or undiagnosed], my condition may require even more complex and costly treatment in the future.

  I have included documentation of my medical condition, and information supporting the medical necessity of [name of service OR procedure], with this letter. Please let me know if any additional information will be helpful to my request. I can be reached at [telephone number].

  Thank you for your immediate attention to this matter.

   

  Sincerely,

   

  [your name]

   

  cc: {Possible individuals and/or groups to whom you consider sending copies of your letter:}

  [Health Plan Medical Director]
  [Medical Group Medical Director]
  [Your primary care physician]
  [Your specialist]
  [Your employer or insurance broker]
  [Your state regulatory agency]

   

  Attachments: {Material and documentation you can consider attaching:}

  • Copies of [health plan] Evidence of Coverage, pp. [#,##] (providing plan's definition of medical necessity, and listing any exclusions and limitations);
  • Copies of medical records, including report from [doctor], lab results from [lab];
  • Copy of letter from [doctor/specialist] supporting treatment (and supporting need for expedited review, if applicable);
  • Referral from [doctor requesting referral];
  • Medical journal articles supporting medical necessity of care sought.