This article was provided by one of our founding board members Julie Portelli. To contact Julie
If you have health insurance, you have entered into a legal contract with your insurer. You make your payments and they should do everything written in the "contract". While it works well most of the time there are times you will receive a denial for a service or treatment. Don't give up – now you have to prove to your insurance company where in their contract it calls for the service or treatment you are requesting. First things first - you need your contract. Not everyone who has "XYZ" insurance has the same contract.
My HMO insurer calls my contract a "Combined Evidence of Coverage and Disclosure Form", and it is a 148 page document. The employer to whom I make my payments is where I was able to get my contract copy (electronically is quicker). If you do not have your contract copy, I would suggest that you get one. You may not have been denied, but knowing some of this information in the future may open up some doors you had assumed were closed. For example, my HMO (not PPO) paid for my out-of-network, out-of-state surgery at a Neuroendocrine Specialty Center.
Please keep in mind if you have been denied services from your insurer, you need to make a legal appeal, not a personal appeal. There is nothing personal about it, and what ever our personal situation is, like how sick we are, how young we are, or how many children we still need to raise has nothing to do with the written legal contract. Not nice, but that is very important information you need to know from the start.
Here is an example of the legal criteria I had to meet according to my contract. This is offered as an example so that once you have your contract you can see similar criteria in yours and this will help you get started.
Most insurers have some sort of "Authorization Program" that provides care or medical services outside of their provider network. We commonly know about this provision for when we are out of town on a vacation and have an emergency. For my non-emergency (planned treatments), I had to get an authorization first by following the "procedures set form in this section". Here is what my contract states;
When an Authorized Referral Will be Provided. Referrals to non-"XYZ" HMO providers will be approved only when all of the following conditions are met:
1. There is no "XYZ" HMO provider who practices the specialty you need, provides the required services or has the necessary facilities within 50-miles of your home; AND
2. You are referred to the non-"XYZ" HMO provider by a doctor who is an "XYZ" HMO provider; AND
3. The services are authorized as medically necessary before you get the services.
Evidence:
1. Access from the internet all the doctors in your insurers network. That is probably easy to prove they do not have a carcinoid/NET specialist. I just attached a list of doctors within the 50 mile radius.
2. My HMO Primary Care Physician gave me the referral, after I gave her the written treatment (surgical) report from the specialist I was seeking treatment with. I had to pay out-of-pocket to get this consultation. My oncologist refused to make the referral. You may have to try more than one doctor.
3. You need to provide documentation that the treatment you are seeking is a proven treatment. Perhaps you have already read many peer-reviewed published articles that have led you to the treatment you are seeking. You will want to include as many of these documents as legal evidence in your letter of appeal.
These resources were very helpful and led me to other people and resources (click on links):
Cancer Legal Resource Center
Lauure the Insurance Warrior
ACOR List
Editors note: You will also need to find out if your company "self insures" in which case the insurance company is acting as an administrator - and the appeals process will be with your employeer. Also as with all information posted on this patient run website, please consult your own team of Doctors and in the case Lawyers.