- Get a complete copy of your policy from your employer or the insurance company and read it carefully before going into treatment.
- If your insurance is through your employer, ERISA is meant to protect you. ERISA is a federal law that regulates health benefits provided through an employer. ERISA requires health plans to comply with procedures for denying claims and appeals. Find out more here.
- Read and re-read the medical necessity definition and guidelines your insurance company or their administrator is using. You may need to request these documents in writing form your insurer.
- Understand your appeal rights and appeal deadlines. These will be provided in your policy and attached to denial letters. When in doubt, the deadlines in the policy control.
- What makes the treatment medically necessary as defined in their guidelines? Put your strongest reasoning in your appeal, along with treatment records and a letter from at least one medical provider confirming that it is medically necessary.
- Put your appeal in writing and submit it on time with a method of delivery confirmation.
- Submit a post-service claim if the denial was pre-service or during treatment.
UP thanks and acknowledges Elizabeth Green and Cari Schwartz of Kantor & Kantor LLP for their contributions to this publication. Ms. Green's practice focuses on ERISA health cases and Ms. Schwartz's practice focuses on bad faith health cases.