Are you worried that your insurance company did not authorize the payment for your reconstructive plastic surgery or only agree to pay small percentage of your claim? If you think you have no choice but to shoulder the high cost of your medical expenses, you still have another option: to make an appeal. Appealing the unjustifiable decision of the insurance carrier will not require you to hire a legal adviser. It is your right to know why they have denied or have reduced the cost of your health benefits. Ask for the copy of the particular statement stipulated in their policy booklet where they draw their decision.
First thing you have to do is to write a letter attention to the insurance representative who is the signatory of the notice of denial. Clearly explain on your letter your basis why they should cover the procedure and you may request that your case be reviewed by the American Board of Plastic Surgery. You will need to gather all the pertinent documents regarding your procedure, billing codes and surgeon’s fee issued by your doctor. Make sure you have in your files the pre-authorization letter of your physician prior to surgery explaining the detailed procedure, request confirmation coming from you, what services are covered, and lastly, the level of coverage for the insurance services.
The American Board of Plastic Surgery Inc. is responsible for establishing clear policy in relation to resolution for appeal. Upon submission of the written request for reconsideration of the case of the complainant, a written notification on the decision of the Committee will be send within 60 days after the evaluation. There is a corresponding appeal fees charge to the appellant depending on the type of appeal, whether it is informal of formal appeal. Prior notice must be received by the complainant at least thirty days before the date set for the hearing.
If your filed complaints were overlooked and you have received merely unclear response on their behalf, you can send a cover letter with an explanation of your current situation and assistance request, also a duplicate copy of your appeal to the insurance commissioner within the local state for the indemnity insurance or to the department of health maintenance organization (HMO) which you are covered.
Everyone would, of course, want a favorable decision from the Committee. But the whole process and the problem it would cause you could have been prevented, if from the very start, you coordinated with the insurance company regarding the total amount of the procedure they can cover under your health insurance benefits. There are some conditions and circumstances for which they will not provide reimbursement from your health plan. It should be discussed during the pre-determination or review process done by your insurance carrier to validate the medical necessity of the planned plastic surgery.