There may be times when you have a dispute with your health plan. First, it is important to review your health insurance policy for the covered benefits and exclusions, including terms regarding “wigs” and “prosthesis.” Health insurance policies may vary greatly. This is important because in most instances, patients will likely have to purchase the wigs before filing a claim for reimbursement. With this in mind, it is important to have a copy of your health insurance policy, the original prescription and receipts/invoices available.
When dealing with your insurance company, we suggest following these steps:
Refer to your insurance plan to find out about required forms and deadlines to file claims for reimbursement.
Keep all paperwork (original prescription and receipts/invoices).
Maintain a written log of your treatment and any contact with the insurance company.
Make sure to write down the name and title of who you spoke with, the date, and the facts of the conversation.
Send the letter certified mail or with a fax confirmation, so you have proof of sending the letter to an insurance company.
Articulate the reasons why you need a wig. Highlight the physical and emotional benefits you will receive from wearing a wig during treatment (protection from the elements including harsh weather conditions).
Don’t forget your doctor and other members of your healthcare team can be allies in the process by giving you documents or medical literature that is pertinent to your claim.
Finally, ask if your insurance company has an insurance ombudsman or case manager. An ombudsman’s role is to assist in resolving disputes between consumers and the insurance company.
Once a claim for reimbursement has been submitted, be sure to follow-up with your insurance company. Ask when they expect to make a decision. In most instances, a claim has to be processed within 30 days. If your claim for a wig is denied, be sure to ask for the denial and reasons for denial in writing.
Internal Appeals
Dealing with an insurance company can be a frustrating exercise, but it is important to remain persistent. Most health plans have established their own internal appeals process to handle these disagreements and they must provide you with that information. Under federal regulations, you have one year to appeal a decision and the company has 30 days to make a decision. When appealing, you should summarize the situation in writing and describe the solution that you desire. When you summarize the situation in writing, be sure to include the series of events and the people involved, including your healthcare team. Also, you can ask your doctor to write a letter and submit supporting documentation about treatment effects and the necessity of a “cranial prosthesis.” When you are appealing a decision, continue the appeals process even if you get first denial.
External Appeals
Many states have an external appeals process. While laws vary from state to state, this process generally provides patients with the right to have an independent review of their health insurance company’s decision. In many cases, you are required to exhaust the internal appeals process first, before turning to the external review process. External reviews are conducted by independent organizations that have medical experts in all specialty areas, who review your individual case. The decision made by the independent medical review organization is typically binding on the insurance company, meaning that the insurance company will have to provide coverage if the independent medical review organization determines that the treatment should have been covered.
If Jane is still denied coverage, she can try to contact community organizations, such as The Luminous Foundation, a local affiliate of Susan G. Komen for the Cure, or the American Cancer Society to help offset the cost of the wig. For more information about navigating insurance coverage, please contact the Cancer Legal Resource Center at 866-THE-CLRC or visit www.CancerLegalResourceCenter.org.