Insurance Appeals

The MAGIC Foundation offers assistance with EXTERNAL APPEALS ONLY to current members of The MAGIC Foundation. Below is information to assist you through the insurance appeals process (including internal appeals)

 

FAQ

Q. I am so confused and just do not understand my prescription drug benefits.
A. Navigating your prescription drug benefits can be confusing! Are you looking to better understand how prescription drug benefits work? If so, click here for a complimentary guide that should answer all your questions.

 

Q. Do you struggle with being able to afford treatment for Pediatric Growth Hormone Deficiency?
A. Click here to download a discussion guide that will help you start the conversation with your doctor about cost-saving treatment options.

 

Q. What do I do if my Prior Authorization has been denied?
A. Consult your doctor as soon as possible and they will file the necessary paperwork.

 

Q. How do I get interim medication?
A. You should be assigned a caseworker from the manufacturer of the chosen medication to aid you and the physician in this process. Make sure the physician is aware you wish to receive medication while beginning the appeal process so that all forms are filled out correctly. 

 

Q. Is there any help with co pay assistance?
A. Click here for a list of programs that may be able to assist

 

Q. Does my insurance cover growth hormone?
A. In the "Medical Policy" section of your insurance packet it should describe what types of growth hormones are covers and for which diagnoses.  

 

Q. What criteria/testing does the insurance need for approval?
A. You or your Endocrinologist can find this out by speaking with your insurance company. 

 

Q. Where can I go for help with the external appeal?
A. The MAGIC Foundation has a fantastic program to help guide you through the steps in the External Appeal Process. This is usually the final step in the appeal process.  This appeal is usually done with the state or outside third party. The doctor usually will not help with this step as it is very time consuming. The MAGIC Foundation is a great resource to aid you in hopefully reversing the denial!

 

Understanding the Appeal Process

 

Your doctor’s office will send a prior authorization request to your insurance company for medications before sending the actual prescription to be filled. Your insurance company will either approve or deny the request within a short period of time (typically 24-48 hours). When prior authorization for the patient is denied, the appeals process begins. Depending on your insurance company and the specific rules that have been established for that particular plan, a member may have the opportunity to appeal one, two or three times. The member should review their insurance plan guidelines to find out how many appeals will be allowed.

Become familiar with your state’s laws and Insurance policy & the insurer’s guidelines.

  • Laws – Some states have laws that define medical necessity and have standards for HMO plans to abide by. These state laws are commonly referred to as statutes and can be accessed on your state’s website.
  • Deadlines – An appeal is allowed a certain amount of time to be filed. It is critical that an appeal is submitted within the amount of time allowed by the insurance company. The denial letter includes the number of days that an appeal must be filed by.
  • Exclusions – Review your actual policy in order to confirm that the treatment you are seeking approval for is or is not covered.
  • Self-funded plan vs. fully insured plan – Check with your human resources office to find out which plan you have. Those with fully insured plans have the option of an external appeal, which is independent of the insurance company, typically submitted directly to the state. Those with self-insured plans have the right to an external appeal however it is submitted directly to the insurance company, which then gets forwarded to a third party reviewer. The employer has the ability to override the adverse decision.

 

Steps to Appeal a Denial

 

  1. Identify reason for denial
    • Does not meet criteria
    • Treatment is cosmetic
    • Not medically necessary
    • Plan exclusion
  2. Create a counter argument
    • Does not meet criteria – Focus on the criteria that the patient does meet, prior to beginning treatment, which is related to the diagnosis. It is not unusual for a person to have a medical condition/disease and experience some of the symptoms rather than the complete list. Many times, the insurance company will have their own set of criteria which can be quite strict and require many more indications for a person to meet compared to the criteria that is suggested by national medical organizations. If this is the case, the appeal should clearly state this fact.
    • Treatment is cosmetic – Clearly state the reasons why treatment is not cosmetic. If appealing growth hormone treatment, focus on other areas of the body that benefit from treatment such as: organ development, bone density, cardiac function. State that short stature may limit the patient’s ability to complete tasks that others may be able to do.
    • Not medically necessary – State that the treatment is necessary in order to treat the diagnosis and that this treatment is recommended by national medical organizations for treatment of the diagnosis.
    • Preparing necessary documents
      • Include your letter of appeal.
      • Include all the insurance companies denial letters
      • Include medical records that relate to the request for treatment (growth charts, labs and test results)
      • Include a letter of medical necessity from one or more physicians
      • Include references for literature from respected & recognized medical organizations
      • Optional - Include a picture of your child that compares your child to his/her peers. Be sure to black out the faces of the other children in the pictures for privacy.

 

Drafting your Appeal Letter

 

  1. At the top of the page, include the date that the appeal will be sent in
  2. Address the appeal to the department and address according to what the instructions state on the denial letter
  3. Provide a short background than includes the patient’s name, age and diagnosis.
  4. Outline the reason(s) that the insurance company’s decision should be reversed and treatment should be covered.
  5. Include contact information for yourself, in case the reviewer has any additional questions
  6. Submitting the appeal
    • If an appeal is sent via fax, a confirmation page should always be printed and kept in a secure place.
    • If an appeal is sent via U.S.mail, it should be sent certified with return receipt.
    • Record the date that the appeal was submitted.
    • Check time frame that your appeal should be processed by and mark that date on your calendar
    • If you do not receive a letter that responds to your appeal with a decision in the established time frame, call the insurance company to make an inquiry regarding the decision.
    • If the insurance company has upheld the denial, then you should appeal again using the same steps and applying them to the most recent basis for the decision

Tips 

  • When communicating with your insurance company, always document the date, time of the call and the person’s name that you spoke with.
  • Mark dates of appeal deadlines and expected dates of responses on a calendar to stay organized
  • Contact your state’s department of insurance if you have questions or concerns and your insurance company is uncooperative
  • When preparing an appeal, do not send in documents that don’t relate to the appeal or are duplicates.

 

Sample Appeal

The following sample information is provided to assist in your appeal.  Please know that each paragraph, bullet or statement may not apply to your situation. Be sure to choose the information that applies to you or your child and fill in the areas with specific information prior to submitting to the insurance company for appeal.  The documents are provided in word format to allow you to cut and paste and print the document.

 

The MAGIC Foundation assumes no liability for the changes you make to the sample documents or other supporting documents provided to assist with your appeal.

 

Sample appeal documents for Growth Hormone Therapy in children:

Sample appeal letter
Sample parent letter
Guidelines for Growth Hormone Treatment in Children and Adolescents (print this document and include with your appeal)

 

Sample appeal documents for Growth Hormone Therapy in adults:

Sample appeal letter
Consensus guidelines for the diagnosis and treatment of adults with GH deficiency (print this document and include with your appeal)

 

Follow up procedure

 

If all internal appeals have been denied and you wish to request assistance from The MAGIC Foundation for your external appeal, please fill out this form below and someone from MAGIC will contact you.  Please know that external appeals are very time sensitive and due to an overwhelming amount of requests, we may not be able to assist you.

 

 

Patient Assistance Programs

 

There are a number of patient assistance programs and co-pay assistance options available. Please check them out to see if you qualify for any assistance.

 

 

"The MAGIC Foundation has been a HUGE blessing to our family. During a time when we continually were experiencing lack of support or avenues to venture down, we came across MAGIC. After hearing so many, I'm sorry I can't help you... or your daughter doesn't qualify... It was refreshing to hear a friendly, warm, reassuring voice on the phone who was optimistic and open to help. It almost felt unreal, but it wasn't! Without the support of the MAGIC Foundation, our precious little daughter wouldn't have been approved for growth hormone therapy. The Insurance Appeals Specialist from MAGIC really went to bat for our family and was by our side the entire way through. She was even present on the telephonic hearing call which was held with a judge and several opposing individuals from insurance companies, which literally meant the world to me! We can not fully express the gratitude and appreciation for what the MAGIC Foundation provides to families like ours. Thank you, for all that you have done and continue to do! It really matters and makes a world of difference to our little children. God bless you all!"               B. Ma, California

 

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