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If your health insurance company ever denies payment for treatments, services, or equipment necessary for your multiple sclerosis (MS), you have the right to appeal that decision. This means that you or your health care provider may submit a letter and documentation asking the insurance company to reconsider its decision to deny payment of a claim for services rendered.
Every person with health insurance, whether it’s a public or private insurance plan, maintains the right to appeal insurance decisions. Since insurers are under increased pressure for health care cost containment and many MS treatments and disease-modifying therapies are very expensive, insurers may potentially deny or limit coverage of specific MS medications, treatments, or equipment. If you have MS, it is important to become aware of the process of appealing health plan insurance coverage decisions.
How To Appeal a Health Care Decision
A health insurance company may make the decision not to pay for the treatment you need and will send you a denial letter stating that the services or treatment you are seeking are not covered under the provisions of the insurance plan policy language, and are outside contract obligations. However, if you and your health care provider believe you need the treatment or service that was denied, you can and should appeal it.
MyMSTeam members discuss their experiences submitting appeals for health insurance decisions. “Appeals are always worth a try. I have won the appeals I filed,” one member said.
You may appeal an insurance denial at three different times:
- Pre-service (before you receive the care)
- When you receive a prior authorization denial
- Post-service (after you receive the care)
The health insurance company’s denial letter will contain instructions, timelines, and rules for submitting an appeal.
Steps for Appealing
Appealing an insurance denial may feel complicated. Following the steps below can help you stay organized.
Revisit Your Insurance Plan Manual
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