Navigating appeals and insurance claims

 

This page contains links to guides and resources for navigating the often confusing realm of insurance claims and appeals for when those claims are denied; these are guides written by GC students and gathered from their experiences. Before looking at these guides, you may want to look at the glossary of insurance terms included in the Student Affairs guide to insurance (see link below). Remember that if you want help with setting up an appeal, you can also contact NYSHIP liaison Scott Voorhees in Student Affairs or the DSC’s Officer for Health and Wellness.

Do you have more tips or guides for navigating claims and appeals? Or questions that you’d like answered on this page? Please use the contact form on the H&W site or email the Officer for Health and Wellness

Guides on this page:
Get Paid Back from Your Insurance: a GC student’s guide
Tips on Keeping Track of Information Information
Sample Letters to Insurance Companies

Links to other posts on navigating claims and appeals:
Elise Perram in Student Affairs’s guide to insurance, including a glossary of insurance terms
Getting Reimbursed by ValueOptions: A step-by-step guide from a GC student
A GC student’s guide to what to do when ValueOptions tries to deny a claim 
A guide to making sure you have the right billing codes when you fill out claims

External links:
PatientAdvocate.org’s guide to Navigating the Insurance Appeals Process
Step-by-step Consumer Guide to Health Insurance Appeals, including sample letters to write for appeals (from disabilityrightslegalcenter.org)
Webinar on Navigating the Insurance Appeal Maze–How to Win and Get Coverage (from christopherreeve.org)
How to write an appeal letter (from BeyondType1.org)

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Get Paid Back from Your Insurance: a guide written by a GC student

 

  • While this guide mostly pertains to getting claims paid for mental health care, most of the steps given here also apply to the other insurance companies bundled under NYSHIP.
  • Note: in any point during this process, if you need support/someone to sit with you while you do this paperwork, please contact the DSC’s Health and Wellness Officer and try to come by the communal DSC office–Room 5495
The basics

For various reasons, you may need to see a provider who does not directly take your insurance.

You may want to call and see if you need prior authorization. Often, a certain number of sessions are allowed without authorizations so you can just go and submit a claim.

Then submit this claim form. (See instructions from this post on how to fill out the forms for ValueOptions).

The NYSHIP handbook tells you what percentage of they will reimburse you–for most therapy you get 80% of a reasonable and customary amount. “Reasonable and customary” means the amount the insurance company believes is appropriate for any given procedure; this amount may differ from the amount your provider charges. In other words, the amount your provider charges might be higher than what insurance considers “reasonable and customary,” which means that the insurance company may end up paying less than 80% of the total cost. Note: they won’t necessarily tell you what the reasonable and customary amount is but if you give a very high amount on the phone they may say no, that’s above our maximum which is ___.

After a certain number of sessions, ValueOptions/Beacon Health Options (the insurance company providing mental health and substance abuse care) may require your provider to fill out an outpatient treatment report (OTR). They don’t do this for psychiatrists, but they do it for talk therapy. You can have them fill it in and give it to you to mail in. Remember, like the claim forms, make a copy or scan it so you can have it to refer to later, or if it gets lost in the mail. Unlike claim forms, you can fax in the OTR (See if the wellness center will let you use their fax). The fax gets it to them faster than the mail.

Best case scenario, they authorize the treatment plan your provider says you need and send you checks.

You may need to call them to remind them to pay you, if, for example, you mailed in your claims before the OTR so they need to go back and process the claims now that they are authorized.

Next best scenario: They say they need more information and request to speak with your provider. They often don’t give your provider many options for speaking and give them only a two day window. You might need to call them back again and say, “Hey, you didn’t get to talk to my provider because you only gave them a few options, all of which coincided with when they were seeing patients, please reschedule.”

Remember, you can ask to speak to supervisors on the phone. Whoever you speak to, be sure to get their name for your records.

Level 1 & 2 appeals

If after they speak with your provider, they still don’t authorize the sessions you need, you will get a denial in the mail. The next step is starting a level 1 appeal. For a level 1 appeal, they basically just call your provider again and have the same conversation. It likely won’t go your way. But it is a necessary step to get to other options.

After a level 1 denial, you can do a level 2 appeal. It’s the same process as a level 1 appeal, and will likely also result in the claim being denied, but it will advance you to the next step.  You don’t have to do any paperwork for these appeals: just say on the phone you’d like to start them. But make sure you time this with when your provider will be available to speak because they will want to speak with them within 2 days.

External (state) appeal

After a level 1 appeal, you can skip the level 2 appeal and go straight to an external appeal (an appeal to the state, rather than to the insurance company itself). It’s unclear whether or not doing a level 2 appeal first looks better for the external appeal. The external appeal is through New York State. The department of financial services will receive your application. Value Options will mail you the paperwork, but you can also find it here. Note, for Value Options, you do not have to pay, but no one will be able to tell you that in advance–just don’t include a check. With the external appeal you should include a letter you write detailing why their decision was unfair. You should also include a letter from your provider and anyone else relevant. For example, if this is about therapy, but you also see a psychiatrist, maybe your psychiatrist can write a letter about why you need therapy with your therapist too.

Once NYS Department of Financial Services (DFS) receives your appeal, they will send it to an external agency. That agency will contact you by mail to see if you have any other documents to add in case you forgot something. Then they send all your materials to a doctor who decides your fate. Some doctors are better than others. Some will analyze your case as if you were a person and say subjective things, like given your childhood trauma, which was a big issue, you do need therapy. Others will look at you like a set of criteria (for example, you have not self harmed in this many months so you do not meet the criteria for this treatment).

State complaint hotline

At any point in this process you can call the complaint hotline run by the NYS attorney general’s office. Their number is 1-800-428-9071. You will talk to a person on the phone and give them the basic info on what you are complaining about. This may or may not result in any actual change–but one thing that is likely to come of it, is they will assign you an intensive case manager–someone for whom you have their direct phone number. You will never have to call the 1-800 number again and talk to a random person at customer service. The intensive case manager is sort of an advocate for you, but also doesn’t have much power.

If all of these steps fail, please contact the DSC Officer for Health and Wellness. While we may not be able to do anything, if we are able to track how many people are going through this we may be able to organize and consider other strategies.

 

Tips for keeping track of insurance information (from a GC student)

  • Keep a file on your computer/on whatever cloud software you use that includes your relevant health insurance information, including:
    • Your member ID for NYSHIP (see you ID card)
    • Your providers’ names, addresses, phone numbers, and Tax ID numbers (you will likely have to ask your providers at least once for this number; providers do not always want to share this)
    • The Group or BIN number for the insurance companies (see more information on “NYSHIP: Who Provides Which Service?”)
  • Keep a spreadsheet (or one spreadsheet per provider) on your computer/on whatever cloud software you use tracking all of your provider visits, including
    • Date of each visit and name of the provider
    • How much you paid during that visit
    • How much $ you claimed from insurance for each visit
    • Whether or not the claim was accepted or denied
    • How much $ the insurance company reimbursed you for the visit
    • Dates of all communications: when the company accepted/denied claims, when you called, wrote, or faxed information to them, when you were reimbursed, etc.
  • Overall, keep records of all communications you have with insurance companies (including the date and who you talked to), of all provider visits, and of how much money you’ve been reimbursed/how much money you have paid. You also may want to keep template letters to insurance companies on hand to save yourself time (look below for a few examples)

 

Sample template letters to send to insurance companies

  • Below are some samples of letters students have sent to insurance companies when appealing denied claims. Feel free to use these as templates for letters to your insurance company

Sample appeals letters
Sample request for retroactive review
Sample letter asking for claims to be reconsidered

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