An “appeal” is a request by the patient his/her authorized representative (such as our office), for a health insurance plan or payer to review and change that denial. It does not involve lawsuits, judges, arbitration or lawyers. It is not done in a courtroom. It is you, as the member, asking them to specifically change a decision which was not in your favor. A patient has special appeal rights as a Member covered under the plan. Surgeons, hospitals and other health care providers also may have separate rights to challenge denials such as requesting a “peer to peer” review, but we are primarily interested in the patient or “member” appeal process since those rights are more powerful. There has to be at least one level of appeal offered, but often a patient has 2 or more appeals to take advantage of. WHAT’S THE DIFFERENCE BETWEEN A PEER-TO-PEER REVIEW AND A MEMBER APPEAL? As cynical as this may sound, many payers will routinely deny pre-service requests for bariatric surgery because they know a percentage of patients will become discouraged and not fight the denial further. You need to know that you have the power and patience to fight for the treatment that has been recommended by your doctor. Your surgeon may also wish to fight for you as well by attempting a “peer to peer” review. This is simply a telephone conversation where he or she will try to speak directly to the Medical Director or others who made the denial decision and get them to change their mind. It is a right most providers have as part of their agreement or contract to treat patients from an insurance plan. These discussions can sometimes be used to successfully challenge some denials.

There are various state and federal laws which require an insurance payer to give patients who are denied coverage a “full and fair review” of denied claims (sometimes called an “adverse benefit determination”). This is called the “internal” appeal because it is a process which is controlled by the insurance company based on the rules and regulations they are supposed to follow. There are generally three types of “claims”:

  • Pre-service claims (requests for coverage of services that have not yet taken place)

  • Concurrent claims (requests to continue authorizing coverage for ongoing medical treatment)

  • Post-service claims (requests to pay a healthcare provider for treatment which has been given to an insured patient)

While our office is experienced with all types of claims, we primarily help patients who are denied before they have their surgery. The majority of health insurance plans, whether they are “self-insured” or “fully-insured,” usually require in-patient surgery to be pre-authorized (sometimes called pre-certified) before it will be covered. (This is often also true if surgery is being done on an outpatient basis as well.)

If your surgeon makes a written request to your insurance plan seeking their approval for coverage of your surgery before it happens, that is called a “pre-service claim” and we can get involved helping you immediately once that request is denied by the insurance plan.

It is CRITICAL for you to contact us the very first time your insurance company has said “NO”! Our expertise makes us a great first option…..NOT a “last resort”! Let’s explore together whether we can help get you approved and on the road to better health.

Our clients benefit from our expertise in a number of areas:

  • Making sure they get access to all available levels of appeal the insurance plan is required to offer until the process is exhausted;

  • Making sure that the people making decisions on the appeal are qualified and without a conflict of interest;

  • Making sure the health plan has all available information in support of the request for treatment

  • Making sure the health plan makes the decision in the quickest time possible

  • Making sure the health plan, if a first appeal was denied, provides all of the information that it is required to give in order for further appeals to be more effective

  • Making sure our clients get the advantage of all the personal contacts and the experience our office has developed while fostering a working relationship with payers over more than 16 years of advocacy

Call 1-877-99-APPEAL for a FREE Consultation





601-C East Palomar Street #480 Chula Vista, California 91911 Tel - 877-992-7732 Fax - 844-384-9199

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