Navigating Insurance Denial: Strategies To Appeal Medication Coverage

Challenging a coverage denial by a health insurance plan is a legal right guaranteed to all insured individuals. Every plan—including private policies, employer-sponsored health plans, Medicare, Medicare medication plans and Medicaid—must provide a process for reconsideration of any adverse determination. When you file an appeal, you are asking your insurance company to reconsider its decision to deny covering a medication, treatment or service for your condition. The potential of having your appeal approved is the most compelling reason for pursuing it—more than 50 percent of appeals of denials for coverage or reimbursement are ultimately successful. Despite the promising success rate, appealing an insurance denial can be a daunting task. To help you get started, we have outlined steps to consider when filing an appeal, key tips to remember, resources to help support this process, and a sample letter.

Understand your policy

When you file an appeal, you are asking your insurance company to reconsider its decision to deny covering a medication, treatment or service for your type 1 diabetes condition. The potential of having your appeal approved is the most compelling reason for pursuing it—more than 50 percent of appeals of denials for coverage or reimbursement are ultimately successful. Despite the promising success rate, appealing an insurance denial can be a daunting task. To help you get started, we have outlined steps to consider when filing an appeal, key tips to remember, resources to help support this process, and a sample letter.

Challenging a coverage denial by a health insurance plan is a legal right guaranteed to all insured individuals. Every plan—including private policies, employer-sponsored health plans, Medicare, Medicare medication plans and Medicaid—must provide a process for reconsideration of any adverse determination.

These can be found in your policy documents or on your plan’s website. If you have a plan provided by your employer, you can check with your human resources department or the member handbook you were provided when you enrolled. If you have Medicare coverage, check your Medicare & You handbook for the specific process.

When you can, enlist the help of your medical provider. Sometimes an insurer says no to a claim because a doctor’s office submitted it under the wrong code, and that can be fixed quickly.

A denial is when your health insurance company notifies you that it will not cover the cost of your medication or treatment. It can be frustrating and sometimes scary if you’re not able to fill a prescription, continue a treatment, or face paying the full cost of your treatment. The good news is, you have the right to appeal the decision. And, while it can be time-consuming to deal with, many health insurance denials may be resolved through the insurance appeals process.

Contact your insurance company

When you file an appeal, you are asking your insurance company to reconsider its decision to deny covering a medication, treatment or service for your medical condition. The potential of having your appeal approved is the most compelling reason for pursuing it—more than 50 percent of appeals of denials for coverage or reimbursement are ultimately successful. Despite the promising success rate, appealing an insurance denial can be a daunting task. To help you get started, we have outlined steps to consider when filing an appeal, key tips to remember, resources to help support this process, and a sample letter.

Challenging a coverage denial by a health insurance plan is a legal right guaranteed to all insured individuals. Every plan—including private policies, employer-sponsored health plans, Medicare, Medicare medication plans and Medicaid—must provide a process for reconsideration of any adverse determination.

Get the full plan document for your policy and read it. It’ll be around 100 pages and will tell you what medical services are covered and detail all the steps needed to appeal a denial. Don’t rely on the four-page summary, she said. It probably won’t help. Likewise, Medicare, Medicare Advantage and Medicaid denial letters should explain the steps to appeal the decision. When you can, enlist the help of your medical provider. Sometimes an insurer says no to a claim because a doctor’s office submitted it under the wrong code, and that can be fixed quickly.

If you have a plan provided by your employer, you can check with your human resources department or the member handbook you were provided when you enrolled. If you have Medicare coverage, check your Medicare & You handbook for the specific process. If your health insurance denied your claim, you can start the appeals process, which has three distinct levels.

First-Level Appeal—This is the first step in the process. You or your doctor contact your insurance company and request that they reconsider the denial. Your doctor may also request to speak with the medical reviewer of the insurance plan as part of a “peer-to-peer insurance review” in order to challenge the decision.

Get your doctor involved

Challenging a coverage denial by a health insurance plan is a legal right guaranteed to all insured individuals. Every plan—including private policies, employer-sponsored health plans, Medicare, Medicare medication plans and Medicaid—must provide a process for reconsideration of any adverse determination.

When you can, enlist the help of your medical provider. Sometimes an insurer says no to a claim because a doctor’s office submitted it under the wrong code, and that can be fixed quickly.

Your doctor may also request to speak with the medical reviewer of the insurance plan as part of a “peer-to-peer insurance review” in order to challenge the decision.

If you have a plan provided by your employer, you can check with your human resources department or the member handbook you were provided when you enrolled. If you have Medicare coverage, check your Medicare & You handbook for the specific process.

The potential of having your appeal approved is the most compelling reason for pursuing it—more than 50 percent of appeals of denials for coverage or reimbursement are ultimately successful.

Request a reconsideration

Challenging a coverage denial by a health insurance plan is a legal right guaranteed to all insured individuals. Every plan—including private policies, employer-sponsored health plans, Medicare, Medicare medication plans and Medicaid—must provide a process for reconsideration of any adverse determination.

When you file an appeal, you are asking your insurance company to reconsider its decision to deny covering a medication, treatment or service for your condition. The potential of having your appeal approved is the most compelling reason for pursuing it—more than 50 percent of appeals of denials for coverage or reimbursement are ultimately successful. Despite the promising success rate, appealing an insurance denial can be a daunting task. To help you get started, we have outlined steps to consider when filing an appeal, key tips to remember, resources to help support this process, and a sample letter.

These can be found in your policy documents or on your plan’s website. If you have a plan provided by your employer, you can check with your human resources department or the member handbook you were provided when you enrolled. If you have Medicare coverage, check your Medicare & You handbook for the specific process. If your health insurance denied your claim, you can start the appeals process, which has three distinct levels: First-Level Appeal—This is the first step in the process. You or your doctor contact your insurance company and request that they reconsider the denial. Your doctor may also request to speak with the medical reviewer of the insurance plan as part of a “peer-to-peer insurance review” in order to challenge the decision.

When you can, enlist the help of your medical provider. Sometimes an insurer says no to a claim because a doctor’s office submitted it under the wrong code, and that can be fixed quickly. Get the full plan document for your policy and read it. It’ll be around 100 pages and will tell you what medical services are covered and detail all the steps needed to appeal a denial. Don’t rely on the four-page summary, she said. It probably won’t help. Likewise, Medicare, Medicare Advantage and Medicaid denial letters should explain the steps to appeal the decision.

Follow the appeals process

The appeals process is a legal right for all insured individuals. You can appeal a medication denial by contacting your insurance company and requesting reconsideration. You can also request to speak with the medical reviewer of the insurance plan as part of a “peer-to-peer insurance review”.

The appeals process has three distinct levels. The first level is the first step in the process. You or your doctor can contact your insurance company and request reconsideration.

The second level is the second step in the process. You can request to speak with the medical reviewer of the insurance plan as part of a “peer-to-peer insurance review”.

The third level is the third step in the process. You can request to speak with the medical reviewer of the insurance plan as part of a “peer-to-peer insurance review”.

You can also request to speak with the medical reviewer of the insurance plan as part of a “peer-to-peer insurance review”.

You can also request to speak with the medical reviewer of the insurance plan as part of a “peer-to-peer insurance review”.

Frequently asked questions