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"Not Medically Necessary" or "Not a Covered Benefit" |
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Amoung the most challenging of appeals are when your HMO
sends you a letter stating "Not Medically Necessary"
or "Not a Covered Benefit". In each of these
cases, the HMO has, in effect, drawn a line in the sand.
Fight back with all your strength and realize this battle
may require resources greater than you. First, you will
have to review a full copy of your plan member handbook
[the Evidence of Coverage (EOC) or the Summary Plan Description
(SPD)], which is basically the HMO contract you agreed
to for this year. See what it says concerning your basic
medical benefits and look for any limitation in the services
they provide. Next, find a passionate physician that will
help champion your cause. Other help may come from hospitals
wanting to perform the procedure…...see if they have
a patient advocate on staff. In this battle all resources
are fair game….use them all. Use your employer, your
benefit manager, your union, AARP, a medical non-profit
or anyone else that could influence the process. HMO contracts
are competitive and are often signed with companies year-to-year
………leverage this fact with those responsible
for your HMO contract….and maintain the highest level
of persistence. PRINT-OUT copies of our Patients Are
Powerful "Not Medically Necessary" or "Not
a Covered Benefit" Sample Letter…use them
as a guide to write your own. You will probably have to
attach documents from your physician to strengthen your
case. Be brief, make your demands up front and insist
that a qualified physician review your appeal. Give a
specific date that you would like to have a response and
speak to the urgency of your need. Explain the possible
negative outcomes that could occur in the face of non-treatment.
Empowered Patients know how to fight, fight, fight. You
are the greatest determinant in the quality of healthcare
you will receive. In the end, it is your responsibility
to demand the best medical care for you and your family.
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