Help with a question regarding insurance appeal.
I recently appealed an exclusion on my health insurance for surgery. My family dr wrote a letter and my sleep apnea dr also wrote one saying that I needed surgery. I also attended a seminar. I sent the letter in certified mail and they received it on August 25th. I waited the 30 days and never heard anything from them. I called them and the guy looked it up and said the letter was received by the appeals department and that he would check into it. He put me hold for like 15 minutes and then came back and said that it was received and that they have 40 days to make a decision and that he would look further into it and call me back. That's been a week ago and I haven't had a call or a letter regarding the decision. Does anyone know what I can do if they don't answer me? Can I get them to have to approve it on some legal loophole since they didn't reply. Any help would be appreciated.
Thanks.
I work in health insurance and here's what I'd recommend you to do. Call the insurance company and speak with two departments. Ask first for the Quality Department. If it were me, I'd ask for the Quality Director - you may not get that person - but it's worth trying. If you have to leave a voice message, call back and ask for the Ombudsperson. You will most likely get a live person that you can speak with for guidance.
There are time constraints and rules associated with notifying a provider/member on Appeal decisions. Those timelines are strict! If there's a delay it could be for a good reason. And a delay may be a positive thing for you in the long run.
Fortunately or unfortunately, approval for services is based on "medical necessity". Taking longer to render a decision is not a reason to automatically approve something may not meet the criteria for medical necessity. Again, the fact that it's taking long than expected could mean a favorable decision for you. Fingers crossed for you!
Sandie
