Paying for COOLIEFWe know that when considering any medical procedure, cost matters, so we want to arm you with information before you talk with your specialist. Answer a few questions below to help find the information you may be looking for.
Do you need prior authorization or predetermination for COOLIEF?Most health plans require doctors to seek advanced approval for most outpatient surgeries, to verify coverage and benefits. This must be done in a specific time frame to provide applicable coding and proof of medical necessity for the procedure.
What is prior authorization?
Prior authorization (sometimes called prior approval or precertification) is the determination of the medical necessity and appropriateness of a specific treatment as a requirement by your insurance provider. While prior authorization does not guarantee that the procedure is covered, if you don’t get preauthorization, you might not get reimbursed. If all the necessary information is submitted for review, the health plan will issue a prior authorization number. The process for getting prior authorization can average from five to thirty days.
Coverage of COOLIEF varies by insurance plan, so contact your health plan provider and ask if they require prior authorization. If they do, your physician’s office may be able to assist you in the process.
What is predetermination?
Predetermination is a voluntary, written request for review of treatment or services, including ones that may be considered not medically necessary, investigational, experimental, or unproven. However, in this review process, your insurance benefit may be calculated before you have the procedure done and the costs may be more upfront. Unlike prior authorization, predetermination is offered by many health plans as an optional review process. Most predetermination requests take an average of 30–45 days to review.
Coverage of COOLIEF varies by insurance plan, so contact your health plan provider and ask if they will provide a voluntary predetermination review. If they will, your physician’s office may be able to assist you in the process.
What to do if you’re denied coverage
Know your rights
The Affordable Care Act ensures your right to appeal health insurance plan decisions. Under this law, if your health plan denies or refuses to pay for care, you have the right to appeal the decision through the health plan’s internal review process.
If you are denied coverage, health plans are required by law to tell you why. You also have the right to file an internal appeal, and your insurer can give you instructions on how to submit the appeal request, the deadline by which to submit the appeal request, and the availability of a Consumer Assistance program (in some states).
There are a few reasons why your health plan may deny your proposed treatment, including:
- Services are not considered medically necessary or appropriate in a specific health care setting or level of care
- The health plan considers the treatment to be investigational, experimental, or unproven
- The service requested is not a covered benefit under the plan
- The claim was not filed in a timely manner
Preparing for an appeal
If your claim is rejected, you can file an internal appeal. This is when you ask your insurance company to do a full and fair review of its decision. Make sure you complete all forms required by the health insurance plan. The COOLIEF team can assist you with this process at 1-844-4-AVANOS. If your state has a Consumer Assistance Program, they can also help file on your behalf. Several internal appeals may be needed before you can move on to an external appeal.
Information on appealing health plan decisions
Find local help for your appeals
Work with your insurance provider to go through the necessary steps to file an appeal. In general, most health plans follow the process similar to the steps listed below.
Request for Reconsideration
First-level appeals are usually reviewed by your health plan’s Appeals Department. The medical director who was involved in the denial may also be involved. Your physician may also request to speak with the medical director as a part of a “peer-to-peer” discussion in order to challenge the denial and have it overturned.
Elevate the appeal
Second-level appeals are reviewed by medical directors and Appeals Department staff that were not involved in the original decision for denial.
Independent External Review
Third-level appeals are usually completed by an independent third party (outside the health plan) who enlists the assistance of a physician who is board certified in the same specialty as the requesting physician. External review means the health plan no longer gets the final say in whether or not to cover the service.
Begin your appeal
Gather information from as many sources as you can. Some of the resources that may guide you are:
- Your benefits handbook from the health plan. This document should identify timely filing requirements for appeal submissions, who to contact, and the best way to reach them
- If you do not understand the information in your handbook or understand the information provided in the denial letter, contact the customer service phone number on the back of your insurance card for additional assistance
- Your physician’s office may be able assist you in the appeal process or supply you with additional clinical information supporting your appeal request
- Your employer’s Human Resources representative may also serve as your advocate during the appeal process
Information to include in your appeal
- A letter of medical necessity (LMN) from your treating physician. The LMN helps to explain why the proposed treatment should be approved and will detail any prior treatments that have been tried and failed. Download a sample appeals letter
- Medical records from the treating physician
- Your own personal narrative that explains why you need the proposed treatment
- Any additional support you can find (such as medical articles, etc)
Pay attention to appeal timelines
Each health plan has appeal timeline requirements, and it’s important to make sure you follow up with the health plan after you submit your appeal packet until you have a determination. The health plan is more likely to move your appeal through the appeals process if you are diligent about your request.
File an external review
If coverage has been appealed but still denied, you have the right to an independent, third-party review of your case. If your state has a Consumer Assistance Program, they can help file on your behalf.
Get a sample appeal letter
This letter is only an example.
Please edit this letter to suit your needs and replace bolded sections with the appropriate information. Remove this portion before submitting to your insurance company.
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