What if the insurance company refuses to authorize payment for the services my provider asks for?

Insurance companies often make doctors and therapists talk to many
different people before they will authorize payment for services.

The
first person with whom your doctor speaks is usually called a
utilization reviewer. This person may not have the training and
experience your doctor has. If the reviewer refuses to authorize care,
your doctor may have to speak with another doctor, who, by the way,
also may not have the training and experience your doctor has.

If
your doctor does not insist that you need the care she requested in the
first place, you will not be able to appeal the insurance company’s
denial.

Your doctor must tell both the reviewer and the
insurance company’s doctor that she will not accept a denial or any
reduction of the services she requested for you. If your doctor does
not insist on her original request, there is no denial or reduction of
services. In other words, if the insurance company gives only part of
what your doctor requested and your doctor does not demand all the
services in her original request, there is no denial decision to appeal
and you lose your appeal rights.

Let your provider know that they must stand up for you through this initial process in order for you to keep your appeal rights.

Sometimes doctors and
therapists don’t know that they haven’t started the appeal procedure by
speaking with a utilization reviewer or with the insurance company’s
doctor. They don’t know that if they don’t clearly insist on the
original request, you won’t get a denial notice and will lose all your
appeal rights. It’s important that you let your providers know that
they must stand up for you through this initial process if you are
going to keep your appeal rights. Click here to get a leaflet that you can give to your providers so that they will know how to deal with your insurance company.

If your provider has clearly demanded the services she originally requested, you have the right to appeal any denial.

Next: (if you have MassHealth) How do I appeal a denial by MassHealth?)

Next: (if you have private insurance) Appealing a denial of care by a private insurance company