Appealing a Health Insurance Decision

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Jump to topics on this page:

• 11 Tips for Appealing Insurance Denials
• Getting a Denial
• Filing an Appeal With Medicaid
• Filing an Appeal With a Private Insurance Company
• Beyond the Appeals Process
• Suggested Links to Additional Resources
   

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You’re at a doctor’s office and you find out that your child needs surgery, a different piece of equipment, or a new medicine. And your child’s health care coverage or insurance provider tells you they won’t cover it.

We’ve been there. We’ve asked the doctor if there are perhaps different ways to help our child. We’ve read through the insurance benefits or called Medicaid to see if a needed treatment was clearly excluded. We’ve tried to find another medicine or a cheaper piece of equipment. But the answer is clear: This specific prescription or surgery is medically necessary. And it’s time to advocate for what our child needs with their insurance or benefits provider.

You have the right to appeal (ask for a second opinion on) insurance and benefit denials on behalf of your child. You have this right if your child has health care benefits through Medicaid, your work, or a private insurance policy. You can appeal a denial whether you are asking for the coverage before your child gets a service or prescription (this is called preauthorization) or afterward.

11 Tips for Appealing Insurance Denials

1. Don’t immediately take no for an answer.
2. Read your child’s policy carefully – research it for approved treatments, equipment, medications, and more.
3. Get a written explanation of the denial.
4. Do not accept filing errors.
5. Ask your insurance agent or group policy administrator at work for help.
6. Contact your child’s insurance company or health care benefits program directly.
7. Complain in writing if phone calls don’t get the job done and keep a copy of letters you send.
8. Write follow-up letters and keep copies.
9. Call the Texas Department of Insurance (TDI) for outside help – 800-252-3439.
10. Get support from your child’s doctors.
11. Keep an eye out for violations by your child’s insurance company or coverage program.

Getting a Denial

Once you – or your child’s doctor – has filed a claim (request for coverage) for your child, your child’s insurer (Medicaid or other insurance plans) must send you a written denial letter if they are not going to cover the requested service. This letter should tell you all the reasons your child’s claim has been denied and that you have a right to appeal. It should also say which person to talk to if you are going to appeal your child’s denial of services.

If the letter doesn’t make the reasons for denial or the appeal process clear, call your child’s claims representative directly (the phone number should be on your child’s insurance or Medicaid card) and have them explain it to you. Take notes on any conversation you have with your child’s insurance or benefits provider about the denial. Put the phone numbers, names, and notes in the place you keep your child’s medical records organized.

If your child has an insurance or Medicaid-related case manager, this is also a good time to call them. Your child’s case manager might be able to help you get a decision changed before you file a formal appeal.

Filing an Appeal With Medicaid

If your child has Medicaid, you can call your child’s Medicaid provider or case manager and tell them that you want to appeal your child’s denial of coverage. They will assign a person to help you with this. In Texas, Medicaid workers must count any phone call disagreeing with a denial of service as an appeal of that denial.

It’s a good idea to call as soon as you receive the denial. There is a deadline to make an appeal, which should be included in the letter you get about your child’s denial of coverage. Make sure to call with your appeal before the deadline and make a note of the time of your call so you don’t have to explain a late appeal.

Medicaid must give you a written decision about your child’s appeal within 30 days of receiving your phone call.

If your child is in an urgent or life-threatening situation, ask Medicaid for an expedited appeal when you call. In this case, Medicaid has to answer you within 1 day of your call if your child is in the hospital, and within 14 days otherwise.

Getting a Medicaid Fair Hearing

If you have made an appeal, and your child’s Medicaid provider still says no, you can ask for a fair hearing within 90 days of the date your appeal was rejected.

You can ask for a fair hearing for your child by calling 800-727-5436 and picking “fair hearing request information.” Or, you can ask in writing and send it to the following address:

Texas Medicaid & Health Care Partnership
Attention: Medical Affairs Support, MC-A13
P.O. Box 204270
Austin, TX 78720-4270

Medicaid will send you a letter with the date and time of the fair hearing, along with what you need to know to get ready. The hearing will take place by phone or in person.

At the hearing, be ready to explain why the denied service is medically necessary for your child. You can bring along your own witnesses like your child’s doctor or therapists, have them on the phone with you, or ask them to send letters explaining this.

You will get a final decision within 90 days of the hearing (or sooner for an urgent need), and your child’s Medicaid provider will have to follow this decision.

Filing an Appeal With a Private Insurance Company

Once your child’s insurance claim has been denied, you can file an appeal directly with your child’s insurance company. This is called an internal appeal. You have up to 180 days (or 6 months) from the date of your child’s denial letter to file this appeal.

To file an internal appeal:

• Write a letter to your child’s insurance company stating that you want to appeal their denial of services to your child. Include your child’s name, claim number, and health insurance ID number. Your insurance company might have a form that you can use. 
• Include letters from your child’s doctors or therapists that explain why this service or prescription is medically necessary.
• You can also ask your child’s doctor to file the appeal for your child (instead of you), or you can call TDI at 800-252-3439 to get help filing an appeal.

Your insurer must send you a decision about the appeal in writing. They must answer within 30 days of the day you mailed or faxed your child’s appeal letter, if you are trying to get preauthorization (insurance approval before your child gets a service or prescription). They must answer within 60 days if your child has already received the service.

If your child is in a life-threatening situation, call your child’s insurance provider as soon as their claim is denied to tell them you are appealing – and follow up with the claim letter the same day. Your child’s insurance provider must give you a decision about the appeal within 4 days of you mailing or faxing in an appeal letter, or sooner if your child’s medical condition requires a quicker answer. In this case, you can file for an external review at the same time that you file your child’s insurance appeal.

Getting an External Review

If your private insurance company still says no to your appeal, or your child is in a life-threatening situation, you can ask TDI for an external review. TDI hires Independent Review Organizations (IROs) with knowledge in insurance and health care to do these external reviews.

To file an external review:

• Fill out an external review form and send it to the insurance company. This might also be called an IRO form. The insurance company should have sent you this form when they sent you the claim denial letter for your child. If they didn’t send it, you can call TDI at 800-252-3439 for help. You can also ask your child’s doctor to fill out this form for you.
• Once your insurance company gets the IRO form, they will get in touch with TDI. TDI will assign an IRO to review your child’s case.
• You (or your child if they are age 18 or older) will need to sign a release form giving the IRO permission to see your child’s medical records. The IRO will get the records from the insurance company and keep them private.
• The IRO will decide within 20 days of being assigned the case if the insurance company will have to pay for treatment, and more quickly if your child has a life-threatening condition. Ask them when they will make a decision when you ask for the external review.
• The IRO's decision is the final step in the state appeals process. Your insurance company must follow this decision.

Beyond the Appeals Process

If you have gone through an external appeal or a Medicaid fair hearing, and your child is still denied coverage, you can go to court. You would need to hire a lawyer who specializes in representing people with disabilities and special health care needs. Texas Law Help can help you find an organization near you that can offer legal services at little or no cost to you. You can also call the Texas Bar Association at 800-252-9690 to get the names of lawyers who have experience working with people with disabilities and special health care needs.

Also, if you believe your child’s insurance company or health care benefits program has not followed the law during any part of the appeals process, you can file a complaint with TDI. The TDI Insurance Complaint Form web page has this form, or you can call 800-252-3439 to get help filing a complaint on your child’s behalf.

If you believe that your child’s Medicaid provider has not treated your child fairly, you can also file a complaint with the Texas Health and Human Services Office of the Ombudsman. You can reach them by calling 877-787-8999 (or 800-735-2989 if you have a hearing or speech disability).