The Insurance Appeal Process

While the benefits of standing are numerous, occasionally, payer sources do not see eye to eye with consumer needs. Altimate Medical is here to help you understand the health insurance appeals process for standing frames.

Purchasing Durable Medical Equipment with Medical Assistance/Medicaid

1. Don't take "No" for an answer. Appeal if denied!
   
   
2. Start by reviewing the documentation that was submitted.
   • Was it complete? For example, does it include the equipment trial process and the individual's specific medical needs?
   • If you are not comfortable reviewing the letter of medical necessity yourself, you can fax (952-937-0821) or email (nancy@easystand.com) us and we would be happy to assist with the review.
   • If further documentation is needed, go to your clinician for help. Photos and/or videos may help convey the information.
     
     
3. Request an appeal in writing. This written request must be received by the payer within a specified time frame, usually 0-90 days (check with your state). Make sure to send a copy of the Medicaid notice of denial with the payer appeal letter. The notice includes needed information such as recipient's name, address, and ID number. Be sure to keep a copy of both the letter and the notice of denial.
   
   
4. An appeals referee will be assigned to hear your insurance appeal. She or he may schedule a telephone hearing. You have the right to an in-person hearing, which is usually preferable. You can, in fact, state in your letter that the hearing be held in person.
   
   
5. Identify potential expert witnesses such as a Physical Therapist, Occupational Therapist, a Psychiatrist, etc. In-person testimony is desirable; however, it is acceptable to have testimony by phone or in a written letter of medical necessity.
   
   
6. It is helpful to have assistance from an advocate or attorney (see our Legal Services & Resources listings). PAAT (Protection Advocacy for Assistive Technology) attorneys are a free resource available to assist persons with disabilities and their families as they seek funding for Assistive Technology (AT).

Purchasing Durable Medical Equipment with Private Insurance

1. Don't take "No" for an answer. Appeal if denied!
   
   
2. Know the insurance appeals process for your payer source by calling your payer source or checking in your policy manual. Generally, there are four types of insurance that may be funding resources for Assistive Technology.
   • Health Insurance
   • Disability Insurance
   • Worker's Compensation
   • Liability Insurance
     
     
3. The process and criteria may vary among insurance policies; most, however will specify a process similar to Medical Assistance/Medicaid’s prior authorization and appeal process (see above).

While the appeals process can be overwhelming, know that you are not alone. For answers to questions, advice on how to move forward, and moral support, make sure to check out our thread on Funding and Appeals in the Standing Room Only Forum.

Whether you are in process of obtaining public or private funding for your standing equipment, the staff of Altimate Medical would love to help guide you throughout the process. Our on-staff funding specialist, Nancy Perlich, can be reached at 877-844-1172 or nancy@easystand.com.

Links
Abledata's Informed Consumer's Guide to Funding Assistive Technology
“Worth Writing for: Writing Letters of Justification and Medical Necessity for Standers.”