How do I Appeal to the Insurance Company for Out-of-Network Provider Coverage?

Health plan members always have the option to appeal an insurance company's decision. If you have received a denial of care or a claims denial because you sought care from an out-of-network provider, you can attempt have the original decision overturned through an appeal. Some health plans types, such as Health Maintenance Organizations, only pay when members to visit an in-network provider. However, in some instances, such as when there is no suitable local in-network provider, you may win an appeal.

Instructions

• 1

  Review any documents containing the specifics of your health plan coverage. Look for this information in your open enrollment materials, on the health insurance plan's website, in materials from your human resources department, or in a summary plan description or evidence of coverage document. Note the type of plan you have and if it allows out-of-network coverage.

• 2

  Confirm that there were no in-network providers in the area where you sought health care services. Most health plans have rules that state if there is no provider within a certain number of miles from your home, you can see an out-of-network provider at the in-network coverage levels.

• 3

  Ask the out-of-network provider if it will write a letter on your behalf for why you should receive its services. If the provider is a specialist and there are no other specialists of his kind in the network, you may have a good argument. Gather any supporting document that shows why you should have this care approved and the original determination overturned.

• 4

  Initiate a formal initial appeal by calling your health insurance company. Tell the representative you wish to file an appeal regarding this denial. You may also file the appeal in writing or have a representative appeal on your behalf. Be sure to include any relevant information that supports your appeal.

• 5

  Receive a written decision from the health insurance company regarding the appeal. Depending on the plan and your coverage, you may have several additional levels of appeal. Keep appealing the original decision until you have exhausted all levels or you receive an approval. Your plan will offer a final external appeal in which independent reviewers, who do not work for the insurance company, will review your appeal and make a binding decision.