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BY LAUREN AGORATUS, M.A.

Families may not know that they have options when a private health insurer or Medicaid denies a claim or reduces or eliminates a service. There can be both internal and external appeals processes depending upon the type of plan. An internal appeal is a second look by the insurance company by representatives not involved in the original decision. An external appeal is when a neutral third party independently reviews the documents.

"NO" PROBLEM: Insurance companies, whether public or private, depend on families taking no for an answer, just going away, and not fighting. Remember, it's in their financial interest to deny claims to save money.

IS IT MEDICAL OR EDUCATIONAL OR BOTH?

Services needed by children with special health care needs can be medically necessary, required under the Individuals with Disabilities Education Act, or both. There is a difference between medical and educational therapies such as physical therapy (PT), occupational therapy (OT), or speech therapy in the home versus school. Sometimes, insurance companies will cut home services if the child gets therapy in school, but families can appeal if the nature of the services are different. The most common services cut are PT/OT/speech therapy and nursing. For example, a child may get therapies through either early intervention (from birth to age three) or special education (age 3-21) and still need medical still need medical DO EVERYTHING IN WRITING AND KEEP COPIES. PHONE CALLS "NEVER services at home or in the community. The IEP (individualized education plan) team, which includes the parents, makes the decision on which related services a child needs in order to benefit from a Free, Appropriate Public Education (FAPE). Home or community-based therapies would be more focused on activities of daily living.

APPEALS 101

Insurance companies, whether public or private, depend on families taking no for an answer, just going away, and not fighting. Remember, it's in their financial interest to deny claims to save money. Most families (2/3) don't even try to appeal. For families with both private and public insurance, this offers the best coverage and many times Medicaid (the payer of last resort) will cover the remainder of the bill after the private insurer pays as much as it will cover.

Do everything in writing and keep copies. Phone calls "never happened." The starting point will be the EOB, "Explanation of Benefits," form or denial letter. This will give the reason for either denying or cutting services. Sometimes it's something as simple as an incorrect CPT (current procedural terminology code) that shows what was done. Alternatively, the ICD10 (International Statistical Classification of Diseases and Related Health Problems), which is the diagnosis code, could be incorrect. On the other hand, it could be something as easy as the doctor's office forgot to include their tax ID number. Many times, additional documentation is all that is required.

The one item that usually turns things around for families is a doctor's note of medical necessity. If the child has more than one condition, multiple doctors' notes will strengthen the case if the service is treating multiple conditions.

Families must make sure they keep at least one copy of everything they use in their appeal. Many times, families will have to resubmit the same information if there is a multi-step appeals process. This is particularly true for external appeals as this is the first time the independent reviewer has seen any of the information from the beginning of the process.

Parents may need more support to appeal claims, especially if they are new at advocating for their child. Families need to remember that they are their child's best "case manager" and advocate, and have a vested interest in the best outcome for their child. Parents can get free help from Family-to-Family Health Information Centers, which will give them information and support on the insurance appeals process. As a last resort, some families may need to get legal help (see Resources).

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THE PERSISTENT PARENT: Families need to remember that they are their child's best "case manager" and advocate, and have a vested interest in the best outcome for their child.

SUMMARY OF KEY POINTS FOR APPEALS

Worst case scenario, many states have Catastrophic Illness in Children Relief Funds which reimburse families for some expenses not covered by insurance (see Resources).

It is important to note that even if a plan is exempt from federal regulation under the ERISA (Employee Retirement Income Security Act), families should still file appeals and copy their State Commissioner of Banking/Insurance because these could be the very same companies trying to get state Medicaid contracts and the state should be aware of systemic problems/concerns.•

ABOUT THE AUTHOR:

Lauren Agoratus, M.A. is the parent of a child with multiple disabilities. She serves as the Coordinator for Family Voices-NJ and as the central/southern coordinator in her state's Family-to-Family Health Information Center, both housed at SPAN, found at spanadvocacy.org

AN APPEALING PROSPECT : ADVOCATING RESOURCES

WEDMD How to Appeal a Rejected Claim webmd.com/health-insurance/how-and-when-to-appeal-insurance-claims#1

FAMILY VOICES/FAMILY-TO-FAMILY HEALTH INFORMATION CENTERS familyvoices.org

NATIONAL DISABILITY RIGHTS NETWORK ndrn.org/about/ndrn-member-agencies

LEGAL AID BY STATE lawhelp.org/find-help

NATIONAL HEALTH LAW PROGRAM healthlaw.org

CATASTROPHIC ILLNESS IN CHILDREN RELIEF FUNDS (click on "Title V in Your State" at bottom of pag)e mchb.hrsa.gov/maternal-child-health-initiatives/title-v-maternal-and-child-health- services-block-grant-program

STATE COMMISSIONERS OF INSURANCE naic.org/state_web_map.htm