How to File a Health Insurance Appeal

Filing Appeals When Your Health Insurance Claim Has Been Denied (Including Payment for HIPEC Treatment)

If your health insurance provider/company has denied your request for coverage for payment for HIPEC, you may need to file an appeal.

Sometimes denials are based on something as simple as improper coding for HIPEC (or any other treatment being denied.) Contact the insurance billing clerk at your cancer treatment center to determine whether the accurate/appropriate code was used to invoice the insurance company for payment of HIPEC.

If you insurance company will pay a portion of the amount the center charges for HIPEC, ask (preferably prior to treatment) if the cancer center will accept the payment offered by the insurance provider, as payment in full.

Aside from coding errors, review the invoice carefully to determine whether any other errors have been charged to your invoice. Additional errors may contribute to the rejection, in part or full, of your claim.

If any coding errors have been resolved, and payment for HIPEC is still being denied by your insurance provider, you may need to file an appeal with your health insurance provider.

Appeals Process

Managed care organizations are required, by law, to have a formal appeals process. Review your health insurance provider’s benefit plan booklet (or access it online) and read the appeal process guideline for your specific policy. Confirm the timeline requirements for filing an appeal; generally, an appeal must be filed within 180 days.

Ask your surgical oncologist to prepare a letter (this should have been prepared during the pre authorization phase prior to surgery) noting why HIPEC treatment is medically necessary for your specific case. This letter should quote appropriate medical journal publications stating the HIPEC is the standard of care treatment for your particular diagnosis. Your surgical oncologist, who proposed the necessity of HIPEC to you in the first place, should be your primary advocate for coverage of payment, especially if or she promotes the use of HIPEC to the medical community and public at large.

Communications with your Health Insurance Provider

When preparing your formal appeal, thoroughly document all communications with the health insurance provider. Notate all communications including those via telephone, email, postal mail and office visits. Include dates, times, specific names and a summary of your communication/discussion.

Include the following information in your written appeals package:

Specific, pertinent medical records and treatment history,
Letter(s) from your specialist(s) explaining why this treatment (in this case, HIPEC) is necessary for your needs and the consequences (prognosis) if coverage for treatment is denied,
Medical journal publications describing the efficacy of HIPEC (see www.pmppals.org for specific examples.)

Additional Sources of Help in Filing your Appeal

Contact your local State Department of Insurance; a listing is provided on the Health Insurance link at www.pmppals.org

If you are insured through your employer, enlist the help of your HR department manager.

If you are insured through Medicaid, enlist the help of your local MediCaid office. Consider contacting the office of your local federal representative for additional assistance.

If you are insured through a managed care organization, follow the company’s written policy for filing an appeal.

Legal Recourse

Consider consulting with an attorney who has experience with health care coverage and benefit denials. Many attorneys offer limited complimentary initial consultations.




The articles published in PMP Pals and posted on the PMP Pals’ Blog at www.pmppals.org are written from the perspective of patients and their family caregivers and are not intended as substitutes for licensed, professional legal or medical advice. Patients should seek the counsel of their own healthcare professionals.
Copyright © 2010 by Gabriella Graham/PMP Pals’ Network/All rights reserved.
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