Appeals and Exceptions for Commercial Health Insurance

Appeals and Exceptions for Commercial Health Insurance

Insurance denying your medical food prescription?
Learn about appeals and exceptions.
When your insurance denies coverage for your medical food prescription because it is not covered, you may still be able to get them to pay for it. This process is called asking for an “internal” appeal or exception. Insurance plans may grant an appeal for a denied claim or approve an exception for a prescription not on their formulary if there is a medical necessity.

To start the process, follow these steps:

  1. Call your insurance plan to ask about their exceptions or appeals process. Some insurances will require you to send them the documentation; others will want to work directly with your doctor.
  2. Your doctor will need to write a letter explaining why you need to take the medication (for example, there is no other medication that is acceptable for your condition that will not cause you harm).
  3. In the case of an emergency, many insurance plans have a number your doctor can call if waiting for a decision in writing will jeopardize your health. By law, an insurance company must make a decision on an appeal within 60 days.
  4. If your insurer denies the internal appeal, you can request an “external” appeal. External appeals are reviewed by independent third parties. Unfortunately, not every state requires insurers to grant external appeals if the benefit is not covered in the first place.
  5. A final step of recourse is to seek legal advice about taking your health plan to court.
  6. At any time during steps 1-5, contact your state and local officials. Click here to send an email to your congressman and senators to let them know you want medical foods covered by insurance.

The Board of Insurance for your state can provide more information about external appeals and also handles complaints against insurance companies.

Learn more about how to file an appeal and view sample appeal letters in this booklet prepared by the Patient Advocate Foundation.

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