Is Your Insurance Company Denying Coverage? What to do next

Why claims are denied

When your doctor prescribes an item such as an insulin pump or continuous glucose monitor (CGM), the pharmacy or durable medical equipment (DME) supplier bills your insurance to process the order. If your insurance denies the claim instead of accepting it, you'll receive a letter in the mail letting you know your claim has been denied.

There are a few reasons this can happen. A billing error is an example of a simple and easily resolved issue that can result in an initial claim denial. Other reasons include a lack of proper authorization or documentation, a perceived lack of medical necessity, or a coverage exclusion. Resolving these latter problems may require more time and effort before your claim is successfully resubmitted.

What to do when your insurance company denies coverage

If you experience your insurance company denying coverage for a health service or item, your journey doesn't necessarily end there. As a patient, you have recourse and steps you can take to resolve this issue.

It can be emotionally taxing to be denied something you need for your diabetes management. It's not personal, even though it may feel as though it is. Understanding the logistics of handling a situation like this can help you stay focused on the task at hand.

1. Find out why your claim was denied. If the letter isn't clear, call your member services line and ask for the details. If you discover it's something like a billing error, find out what the proper code is so you can provide that information to the pharmacy or DME company.

2. Gather necessary paperwork. If the denial is based on something other than an error, you'll need to address the issue with the required documentation. This might include a letter of medical necessity (LMN) from your doctor, blood glucose logs, or some other paperwork that underscores your need for the item in question. Work with the other players (physician's office, pharmacy or DME supplier, and insurance company) to attend to all these details before the claim is resubmitted.

3. Prepare for a formal appeal process. If your health insurance company denies coverage, you have the right to appeal their decision and have it reviewed by a third party. An internal appeal occurs when you request that your insurance company performs a full and fair review of its decision. You also have the right to an external review, in which a third party determines whether or not your claim should be paid.

If you decide to file an internal appeal, follow the directions provided by your insurance company. They are legally obligated to provide clear instructions about the appeal process so you can work with your doctor to gather all necessary information and forms for a successful appeal. Your doctor may be asked to speak to a physician through the insurance company in what is called a peer-to-peer review prior to filing a formal appeal.

At the end of the appeal process, your insurance company must provide you with a written decision. If they deny coverage, you can ask for an external review. The insurance company's letter must include information about the external review process.

If at first you don't succeed, try again

There are many reasons claims get denied, but just because your claim was initially denied, it doesn't mean that's final. Whether it's a simple error or a more complicated reason, there are options for handling the issue and processes to ensure your needs are given the consideration they deserve to determine coverage.

Have you been wondering how to get your diabetes supplies through your insurance? Learn more about this process on Edgepark Health Insights.