If your health plan denies you coverage or refuses to pay a claim, you have the right to appeal that decision or have it reviewed by a third party. If your appeal is accepted, you can be reimbursed by your insurance company for the services that they failed to cover. There are two ways to appeal a health plan decision from an insurance company:

1. Internal Appeal: A full and fair review that is conducted by the insurance company. An appeal needs to show that the medications or healthcare services that were denied should be covered by the plan based on its own rules and that the services are both appropriate and medically necessary. You can ask your insurance company to speed up this process if your case is urgent.
2. External Reviews: Occurs when an independent third party reviews your case. Your insurance company does not have a final say over whether to pay a claim.

Learn more about the process for an internal appeal on Healthcare.gov.

1. File a Claim: A claim is a request for coverage. Either you or your healthcare provider will usually file a claim to be reimbursed for the costs of your treatment or services.
2. If Claim is Denied: If your health plan denies your claim, they must notify you in writing and explain why it was denied:
   
   1. Within 15 days if you’re seeking prior authorization for a treatment
   2. Within 30 days for medical services already received
   3. Within 72 hours for urgent care cases
3. . File an Internal Appeal:
   
   1. Complete all forms required by your health insurer. Or you can write to your insurance company with your name, claim number, and health insurance ID number.
   2. Submit any additional information that you want your insurer to consider. This can include a letter from your provider.
4. If you don’t want to file the appeal yourself, the Consumer Assistance Program (CAP) in your state can file one for you. To find a CAP near you, visit the Centers for Medicare & Medicaid Services website.

Your internal appeal must be filed within six months (180 days) after receiving notice that your claim has been denied. If your situation is urgent, you can ask for an external review at the same time as your internal appeal.

You may also request an expedited appeal process, and request that your next reviewer for medical services be a specialist in neuromuscular disorders, if possible.

Your insurance company may not grant this request, but it at least makes clear that a non-specialist may not fully understand the clinical factors involved in determining what is appropriate and medically necessary care in your case.

If your utilization reviewer fails to explicitly state why you were denied coverage and only cites that services are “not meeting criteria for medical necessity,” you should call your insurance company and ask for the specific criteria they used in making their decision. The telephone number for your insurance provider should be listed on the back of your insurance card. You have the right to request a copy of the medical necessity criteria being used to make the determination. If you are directed to a website from your insurance company, ask them to guide you to the correct page over the phone because it may be difficult to find online. You can request to speak with a supervisor if you aren’t getting the help you need from the employee that answers the phone. If your insurance company still denies your claim, you can file for an external review.

For details about the process of an external review, visit the HealthCare.gov website.

1. File for an External Review: You must file a written request for an external review within four months from the date you receive a notice or final determination from your insurer that your claim has been denied. You may appoint a representative, e.g. your doctor or another, to file an external review on your behalf.
2. External Reviewer Issues a Final Decision: An external review either upholds your insurer’s decision or decides in your favor. Your insurer is required by law to accept the external reviewer’s decision.

There are multiple types of denials that can go to external review:

• Any denial that involves medical judgment where you or your provider may disagree with the health insurance plan.
• Any denial that involves a determination that a treatment is experimental or investigational.
• Cancellation of coverage based on your insurer’s claim that you gave false or incomplete information when you applied for coverage.

In addition to requesting an expedited appeals process, you can also request that your next reviewer for medical services be a specialist in neuromuscular disorders. Your insurance company may not grant this request, but it will make clear to them that a non-specialist may not fully understand the clinical factors involved in determining what is appropriate for your care as a person with DM.

For any additional questions about insurance coverage and how to start the appeal process, contact Myotonic at 1-86-MYOTONIC, or email us at info@myotonic.org.