Monday, November 12, 2012

Appealing denial of coverage

When you are denied coverage for a medical procedure or a prescription drug it is important to do an appeal with your insurance company.  If you have a Medicare sanctioned plan the appeals process is governed by Medicare law.  Sometimes it takes a couple of iterations to get to an independent group (that is - not the private insurance provider) to get a fair assessment.

I just wanted to remind you that IBM secondary insurance and Aetna Integration insurance is not governed by the Medicare appeal process laws because it is not government sanctioned medigap or secondary insurance.  For those insurance policies if you are not satisfied with the decision they render you have to complain to the department of insurance in your state.  It is unlikely doing that will change the decision but it is important to complain because those departments track complaints and put pressure on insurance companies that are generating a lot of complaints.

I don't know what the appeals process is for IBM's prescription drug insurance plan.  Although it is a "creditable" plan, I am not sure if the company (CVS Caremark) is required to have the same appeals process as a government sanctioned prescription drug plan (PDP).  If you are choosing the IBM prescription insurance plan you should ask the question.  If it does not conform then your appeals are totally handled by CVS - which means there is no independent review and your chances of reversing a decision are slim.  If someone has an answer please post a comment.

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