11 Step 1: Determine the reason for the denial. Contact your insurance company or wait for them to send you an Explanation of Benefits. An EOB must be sent to you in writing within 15 days if you were seeking authorization for a treatment, within 30 days if the service has already been performed, or within 72 hours in cases of urgent care. Common reasons for denials are: • the treatment or service is not considered medically necessary by the insurer • the provider is not in your insurance company’s network • the treatment is considered experimental or investigational • a brand name medication is ordered and the company requires generics be used, if available • a medication is not on the insurer’s formulary (a list of approved medications) • the insurer requires you to try other, less expensive medications first Step 2: Appeal the denial following the insurance company’s internal process. Assuming you disagree with the reason for the denial, you can file an appeal. Your EOB typically provides instructions for doing so. You may need to provide additional information to show why your claim should be covered. This may simply involve asking your doctor’s office to contact the insurer and explain why the use of a particular treatment or medication is indicated. Your doctor can also request a peer-to-peer review, in which they communicate directly with a medical reviewer at the insurance company. Step 3: Ask for an internal review If a simple appeal does not result in coverage, then a second level of internal appeal can be requested. In this event, a medical director for the insurance company, who was not involved in the original denial, reviews the claim and any additional documentation provided by you or your healthcare provider. This will result in a final decision from your insurance company about your claim. Step 4: Ask for an external review If your insurer provides a final decision with which you disagree, under the ACA you have the right to an external review. In this process, an independent reviewer and a doctor, with the same specialty as your doctor, will review the case to determine if the insurance company should cover the claim. The company is legally bound to abide by the ruling of the independent reviewer. Some may wonder, is it worth going through the process to appeal? It depends on your circumstances and how important the service or treatment denied to you is in your overall treatment plan. However, it is worth noting that more than half of all appeals are successful. If you and your doctor believe the denied treatment is vital for your health, fight for it! Perhaps the most critical decision about your care that you and your doctor make is about your disease-modifying treatment.