The ability to make a successful clinical appeal when requested treatment services are denied by an insurer is an important skill for psychiatrist to have in today’s environment. No one strategy will prove successful at all times and in all situations; often success will lie in a combination of approaches depending on the case in hand.
Letter Appealing Treatment Denials From Commercial Insurers
Any letter written to appeal a denial should include a response to the specific reasons given for the denial. Before writing a letter you must request the reasons for denial in writing, if you have not already received this and also request copies of any plan guidelines that were used in support of the denial. It is possible that you will find support for the medically necessary treatment within these documents. Any denial of treatment should provide you with the information on where to direct your appeal.
[Name and mailing address of payer]
To Whom It May Concern:
I have been seeing [patient name] since [provide date care began] to treat his/her [provide diagnoses, and any problems this may cause in patient’s life if applicable. For example: Anxiety that has limited her ability to fulfill her duties at work].
[Provide a chronology of the patient’s treatment and explain why you need to either continue or initiate the denied care. If the company is denying the frequency of care, the chronology will provide an example of how patient decompensated when care was provided with less frequency. If the denial is for a medication, provide a history of prescribing and explain why you have come to the decision that it’s necessary to either continue or initiate treatment with the denied drug. Explain any of the patient’s stated concerns/preferences that influenced your decision. Be sure to provide examples of what might occur if care continues to be denied and how this would be detrimental to the patient’s health. Always be as specific as you can.]
I have attached articles that support provision of this care to [patient name]. [if you can find literature to support the care that is being denied, this can be a very valuable asset. The APA’s Practice Guidelines can be a good source for support since most insurers say they use them in developing their treatment guidelines.]
[Name and contact information]