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Health Coverage Denied? File an Appeal


Have you had the experience of having your health care plan deny your ADHD-related claim? Perhaps it had to do with an evaluation or prescription coverage. Many people will experience, at least once, having a claim declined.

Most often, the National Resource Center’s helpline hears from members of the ADHD community who have had medication coverage declined. So how can you proceed if this happens to you?

  • Find out specifically why the medication was not covered. Sometimes the pharmacy can tell you or you may need to call your health insurance company directly. Common reasons include the medication is not among the ones the insurance company covers, it’s a name brand rather than a generic, or the insurance company does not cover that type of medication for adults but will cover it for children. If you call or email the insurance company to ask for the reason, be sure to request documentation on the answer you receive.

  • Get your doctor’s office involved. Your doctor may be able to prescribe a medication that is covered by your health insurance or a generic form. The doctor’s office may also be able to contact the insurance company directly and state the medical need for the prescription. Some insurance companies will request a letter from the doctor’s office about the diagnosis and prescription as part of their process to authorize treatment.

If your insurance company continues to decline the prescription coverage, you will likely consider an appeal. Contact your insurance company for an outline of the appeal process and what documentation is required. Follow the process, again involving your doctor’s office and, if appropriate, your pharmacy.

During your appeal process be sure to:

  • Continue to apply for coverage or continue to resubmit the bill for the prescription for reimbursement, even if you are turned down during the process.

  • Keep documentation of your steps and any information you receive from the insurance company. Keep conversations in email as much as possible. If you do speak with an employee from the insurance company by telephone, keep a log of when, who it was, their title, their contact information, and what was discussed, for easy reference.

  • Find out the cost of your medications and be willing to negotiate for partial coverage if necessary.

  • Put all filing deadlines on your calendar with reminder dates scheduled ahead of time.

If you are unable to resolve the issue with your health care plan, you can contact your state’s health insurance commissioner to discuss an external appeal.

For more information on health insurance, paying for medications and pursuing an appeal or grievance, visit The Insurance System. If you need help applying for insurance, visit HealthCare.gov.


This article appeared in ADHD Weekly on March 31, 2016.
     


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