Do's and Don'ts of Appeal Letter Writing

For the newbies - I try to keep this posted often. Hope it helps! ***************************************************** DO indicate the reason the claim was denied should be refuted, with the original denial wording used quoted in your appeal letter. DON'T use a form letter. Every situation is different. Nothing looks more stupid than a letter that addresses every issue under the sun, with the exception of the reason for YOUR denial. DO specifically link all medical studies to the patients individual situation. DO highlight Medical records submitted in your appeal as to doctor treating (name), dates, diagnosis, treatment, etc. DON'T beg your insurance company to approve surgery. When you show weakness, they want to go in for the kill. There's nothing more wonderful than the smell of fear or pity to make some burned out insurance company rat get excited. Rather, write a good factual appeal letter, pointing out where they erred in their decision. Support your facts with good documentation from your attending physicians. (Your medical records.) Keep it as objective and non-emotional as possible. all personal, subjective statements should be removed. The denial will be overturned on the merits, not sympathy. DON'T ever take anything the insurance company says over the phone as accurate. Demand that all correspondence be in writing. Get a copy of your policy, since they may quote a policy provision that isn't even in your policy. THIS IS CRITICAL. I can't overstate this enough. DON'T fax an appeal, or any added documentation. Rather, send it certified, return receipt requested, or overnight so that you have proof of receipt. ALWAYS send a copy of your appeal (in the same manner) to the Vice President of Group Medical Claims. Be sure you indicate on your appeal that copies were sent to the VP, the Insurance Commissioner in your state, (unless it's an ERISA plan which isn't governed by state law.), and all of your physicians. DO use good grammar and spelling. Have a trusted (intelligent) friend proof read and edit for you. You don't want your typos or poor grammar to distract from your intention to sway them to your way of seeing things. If you are not a good writer, consider having a friend, consultant or attorney write the letter for you. THIS IS YOUR LIFE! DO request that the appeal be reviewed by an outside, 3rd party physician reviewer if the appeal is not overturned internally. If you are on an ERISA plan, you have the right to appeal within 60 days of the denial. The clock is ALWAYS ticking. DO request the names and credentials of the insurance representative *****viewed your records, and copies of the specific records that were reviewed. Also request copies of any "expert medical opinions" secured by the company in making it's decision. ALWAYS keep a detailed log of when you called the insurance company, the date and time, the first and last name of the person you spoke with, the questions you asked and the answers you were given. This is imperative! Fight the good fight! Roberta

THANKS! Hoping I will not need this, but thanks for posting it!