The Patient Education Sheet, Health Insurance Tips – Part 1, contains tips on obtaining healthcare reimbursement. Part 2 addresses how to appeal a decision if you are denied coverage. Always appeal a denial! Be persistent and do not give up when first denied.
Information and documentation that will help you appeal a denial
- Your policy and claim numbers, employer name if your policy is through an employer, and the full name of the insured
- The therapy or procedure for which you were denied and why the denial letter stated you were denied
- Medical records that back up your diagnosis and medical problem that relates to the therapy in question
- A cost-benefit analysis when relevant - For example, you can compare the cost savings of obtaining punctal plugs or cauterization compared to the higher cost of having to pay for more moisture drops and ointment over a long period of time.
Letter of Medical Necessity
- This letter is usually written by the physician explaining why a therapy or other treatment is medi- cally necessary.
- If the Letter of Medical Necessity is not signed by your physician, have your physician provide a let- ter of support for your appeal and reason for recommending or prescribing your therapy.
- A Sample Letter of Medical Necessity for dental treatment can be found on the SSF website under “Brochures and Resource Sheets.”
Quotes from your health insurance policy that are helpful to your case
- For example, if your policy states that coverage is provided for a closely-related disease and/or similar symptom, quote that back to the insurance company. If the company cites a reason for covering the related disease or symptoms, such as an inflammatory response, use that. Quoting such statements and providing documentation about similar occurrences in Sjögren’s increases your chance for the success of an appeal.
- Cite two or more articles from respected medical journals backing your claim of medical necessity.
Refer to the SSF website as an authoritative source of medical information on Sjögren’s.
For more information on Sjogren's, contact the Sjogren's Syndrome Foundation at:
6707 Democracy Blvd, Suite 325, Bethesda MD, 20817
800-475-6473 www.sjogrens.org firstname.lastname@example.org
Clinicians: Please make multiple copies of this Patient Education Sheet and distribute to your patients.