Get the Denial in Writing to see what the reasoning is for denying the equipment. Many times, funding sources will contact your supplier's office on the phone to say that they are denying your equipment request. This is an unacceptable form of notifying you and the supplier of the denial. It is your right to get any denial for your equipment in writing.
If you do not have the actual denial in writing, it will be difficult, if not impossible, to proceed through the appeals process. This is especially important if your claim ends up going to a fair hearing.
It is worth at least one level of appeal if you get a denial based on an item that's "non-covered." Know your policy well! If you can prove the item qualifies as DME under the policy definition or qualifies under the definition of 'medical necessity' for your specific needs – then it should NOT be considered excluded.
Private Insurance Companies
May have excluded items because they fall outside of their:
Policies may exclude some items such as:
May not deny any item because it's 'not covered.' All decisions in Medicaid must be made based on individual medical necessity.
If your receive a denial that offers you instead a 'least costly alternative' to the equipment requested, you should take the following into account when filing your appeal:
If your receive a denial stating that the equipment requested is 'not medically necessary,' you should take the following into account when filing your appeal:
Each insurance company has its own definition of medical necessity. It is imperative for you to know how your insurance company defines medical necessity and what criterion you need to meet in order to qualify for a wheelchair.
There are many ways to find your insurer's definition of medical necessity:
If you receive a denial for reasons such as age, diagnosis, or life expectancy, then your appeal will cite federal law pertaining to discrimination.
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It is very important you review your insurance handbook for details to combat the denial in an appeal. If you do not have your handbook anymore, you can go to your insurer's website for information or call customer service to request a new handbook.
There are many different policies for each insurance company. The best way to find out the appeal policy for your particular insurance plan is to check your member handbook. Look under appeals or grievances for more information or contact your insurance company. Listed below are some general appeals processes for each company listed.
If you do not see your insurer listed above, go to your insurer's website or call their customer service line to learn the process for appeal.