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A Patient's Guide to Appealing Insurance Decisions
By contactus@towsonimplantsperio.com
September 20, 2016
Category: Uncategorized

Walking up from the mailbox and into the house, a quick sort of the thin business envelopes comes with zero anticipation. You find the same old things, utility statements, community mailers, fast approval offers, but then there’s that letter from your dental insurance company. Your index finger becomes the key to a Pandora’s box of questions when your eyes fall on the words “payment denied.”

If you’re like most of us, the “uh oh” moment has dawned. Trying to remember why you’d visited the dentist or doctor and what you had done, you read on in bewilderment. Sure, the letter reads that “this is not a bill,” but you know one will soon arrive. So what now?

First, know you’re not alone. Second, get ready to appeal.

When should I appeal?

When you see the term “not medically/dentally necessary”

Preauthorization is “required” for this procedure

When alternate benefits are provided for a service which you would otherwise have coverage (example: implants/bridges/fixed partial dentures/crowns, periodontal maintenance)

When an emergency takes place before a waiting period has expired- In this case, consider asking for documentation so that you can file your dental conditions with your medical carrier. In many cases your medical insurance will accept a printed dental claim for you submit to them yourself. You can also try checking to see if your dental policy has an accident rider providing separate coverage. Towson Center for Dental Implants and Periodontics' staff can help you get this information.

Before you appeal…

Know what you’re talking about. Just because you think your dental insurance should pay for something, it doesn’t mean you have coverage for it. Be aware of the maximums your plan may have in place. Benefits cannot be paid on your behalf if you’ve already used all of them.

Make sure your healthcare or dental provider has also filed an appeal or has already exhausted any efforts to do so from their end.

Understand how your insurance company accepts appeals. Federal law requires insurers to allow patients to appeal any adverse medical or dental decision. Some insurers require appeals be filed via secure forms online. In most cases, a written appeal is still accepted and recommended in addition to an electronic one. Make sure you have the appeals filing address. It is usually found on the statement you get from your insurance company. If not, call the phone number for customer service on your card and ask.

For Best Results…

With your written appeal, send a copy of the insurance company’s initial decision, usually called an Estimate of Benefits (EOB) The EOB is the letter that started the chain of events here. Note the claim/case/account number on the EOB on your written appeal. This number is assigned by the insurance company.

Log your contacts with your insurance company. Get the name of who you talked to, what day and time it was and if at all possible, get a call number or reference number for the call so that your communications can be cataloged. Log contacts with your healthcare provider also and if at all possible, speak with the same representative each time.

Send your medical/dental provider copies of any appeal you may write to be included in your record. This may help delay any collections and keep a positive relationship with your provider. Provider administrators work hard to get insurance companies to pay on behalf of patients. Offices appreciate knowing patients are taking care of business themselves, too.

Follow up. Wait a week or two, then call and follow up on your appeal request. Depending on the state in which you live, you should hear quickly that your request was received. Actual decision re-processing may take up to 30-days. Keep checking and again, log your contacts!

If you have obtained your coverage through an employer, it may be beneficial to ask the HR or benefits coordinator for assistance.