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Appeal Denials to Specialists or Non Participating
Providers
Don't pay hundreds of dollars in
consulting or attorney's fees. Go
To Appeal Letter Order Form
HMO plans usually are the most limiting
in their availability of Specialists for their members. The
primary reason is that each month they pay their primary care physicians
a capped dollar amount to see a specified number of members.
However, if a patient must see a specialist, the payment may come from
the primary care physician's pocket, in terms of a reduced bonus or
monthly payment. Health Plans in general try to contain the
visits to Specialists because their cost could be quite large. Some important
things to know about Specialists denials, include:
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For most health plans, you must
obtain a referral from your primary care physician. If one is
not obtained, it would be very difficult to overturn this denial.
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You must also obtain an authorization
where required by your health plan.
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Your symptoms/diagnosis required for
Specialists care must be specific and detailed by your physician in
your medical chart.
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Denials could be properly appealed
depending upon the support by your physician proving medical
necessity and the focus of your argument within the appeal letter.
How do you combat a denial to a
specialist? The following steps may help.
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Review the denial with your policy booklet and verify that their denial is
justified. If their reason for denial is unclear, call the customer service
unit at the health plan for a more descriptive explanation. Record your
conversation and document the name of the individual you spoke with for
future reference.
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Does your health plan cover Specialist care
and did you abide by the policy and limitations by the plan?
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Verify that the Specialist Care you sought is a
covered benefit under your health plan. If not, then you
will need your physician's assistance to appeal to the health plan with a letter
of medical necessity and all accompanying medical records (pathology
reports, operative reports) required by the health plan to justify the
medical treatment by the Specialist.
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Appeal the denial yourself by
using one of our Appeal Letters. Our Appeal Letters have
been used by actual medical providers and provide arguments embedded
within the Appeal Letter to make your case to the health plan to
overturn your denial. To review available appeal letters, click
here and review the List of Available Appeal Letters related
to Non Participating Providers.
[Go to Common Insurance
Denials Page] [Go
to Home Page]
Health
Symphony Copyright ©
2008.
All rights reserved.
Health Symphony provides information as a general resource
and does not guarantee any results, expressed or implied, obtained from its use.
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