Medical Insurance Appeals

Medical-Insurance-Appeals

BY BETTY MABERRY, JORDAN SMITH, AND ASHLEY TAPP
THE HELPDESK TEAM

Employees who are eligible to join employer sponsored group medical plans benefit from many advantages such as negotiated rates with in-network providers, coverage for a robust variety of medications included on a plan’s Prescription Drug Formulary, and grievance or appeals rights.

Members always have the right to submit a grievance or appeal when a complaint arises due to the denial of a claim, and instructions can typically be found on the Explanation of Benefits, the denial letter, or the plan summary documents. The Bottoms Group HelpDesk team is always here to help members understand how a claim processed and to assist with determining how to proceed from a denial.

Why would a member choose to file an appeal? Appeals can be submitted to the plan for any reason; however, recently a member contacted our TBG HelpDesk for assistance filing an appeal due to a denied prescription.

Medical plans include coverage for a variety of prescription drugs, and they use a Prescription Drug Formulary to determine the cost and coverage of the medications. Members and plan sponsors can request a copy of the Drug Formulary, and most insurance plans include a searchable formulary on their online member portal. The formulary provides details such as the coverage tier, the presence of any quantity limits, and confirms if step therapy may be required.

Our TBG HelpDesk team was recently contacted by a member with active group medical coverage after a prescription refill request was denied under the medical plan. While this member was new to the employer medical plan, he had been using a medication for years previous that he and his doctor found worked best for the treatment of his medical condition.

When his medical coverage became active and he attempted to refill his prescription, the claim was denied because the Prescription Drug Formulary required step therapy before approval. Step therapy is sometimes required by insurance companies as a way for members to try a lower cost alternative before the plan will pay for the more expensive version.

In this instance, since the member already tried the lower cost alternative without success, our HelpDesk team advised that the best course of action would be for the member’s provider to file an appeal on the member’s behalf. With the provider filing the appeal to the insurance company directly, the provider could be sure to include all past medical records and be able to conduct a “peer-to-peer” review if needed. Fortunately, due to the medical records provided, this member’s prescription claim was ultimately approved, and the member was able to fill the prescription and continue their treatment.

Members with active coverage are able to use the Prescription Drug Formulary and other tools included on the online carrier member portal to better understand their coverage. Rest assured, our HelpDesk team is always here to help you and your employees better understand how claims process, and to determine the next steps following a claim denial.

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