Tips to Help You Appeal a Denial From Your Managed Care Health Insurance Plan (MCHIP)

Tips to Help You Appeal a Denial From Your Managed Care Health Insurance Plan (MCHIP)
Each MCHIP has a specific process to resolve complaints, appeals, and grievances.
Your Evidence of Coverage (EOC) and other plan documents outline the process and
contain information on how to appeal a denial.  If your MCHIP has denied something,
such as authorization for services or payment on a claim, you can appeal. If you
submit a written appeal to your MCHIP, they are required to respond in writing.  You
can also call your MCHIP and a representative will provide information to assist you.
You can also call us at the Office of the Managed Care Ombudsman for assistance.
Here are some tips to help you make an effective appeal.
Clearly state what you want to appeal and why.  Identify the specific service or
claim that you are appealing and if applicable include the date of service, provider,
claim number and any other information that will help your MCHIP know what you are
appealing. Determine if your appeal involves a medical issue, such as payment or
authorization for services you believe were medically necessary, or an administrative
issue, such as a benefit that was denied because your MCHIP states the benefit was
not eligible for coverage.
Discuss the problem directly with your MCHIP. Contact a customer service
representative and learn all you can about the issue you are appealing.  If you have
a denial letter, contact the individual identified in the letter as
the point of contact.  Take notes to include the date, name of
the person you speak with, summary, and final outcome of your
discussion.  If the conversation indicates the problem will be
solved, check back with your MCHIP if the problem is not
resolved in a reasonable time.
Involve your treating health care provider.  If your appeal involves denial of
treatment your provider believes is medically necessary, ask your provider to contact
your MCHIP and discuss the issue.  Your provider can contact the MCHIP’s medical
management section to discuss the request.  Such direct discussions often resolve the
problem.
Submit a written appeal. If neither you nor your provider can resolve the problem
over the phone, send a written appeal to your MCHIP.  Carefully read your EOC and
other documents to gather information that supports your position. Clearly explain
why you believe your position is correct, and write in a business-like manner.  Focus
your argument on the facts that support your position.  Specifically state why you dispute the decision, and if you have received a denial letter, address each reason for
the denial in the letter.  Provide specific information and concentrate on facts.  Be
sure to include your name, identification  number,  address, and telephone  number.Make a copy of your appeal before you mail it to your MCHIP, and consider using
certified mail; return receipt requested to ensure your appeal is received and so you
have proof as to when and by whom it was received.
Follow up on your appeal.  If you do not receive an
acknowledgment within a few days, call your MCHIP and ask if they
received your appeal.  Follow any instructions included with any
acknowledgment letter you receive and ensure you understand the
next step in the appeal process.  If you send your appeal via
facsimile it is very important to call your MCHIP and ensure they
received your appeal.
Understand and use the appeal process.  The EOC and letters you receive from your
MCHIP will contain an overview of the appeal process.  Be sure to understand how
many appeals you have under the MCHIP’s procedures, and whether the procedure
permits you to meet with the MCHIP to present your appeal in person.  If your
internal appeal is denied, you may be eligible for the Bureau of Insurance’s External
Review program. You can obtain information on the External Review program by
contacting your MCHIP or the Office of the Managed Care Ombudsman.