Coverage Appeals by Physicians and Patients
Providers and patients can appeal an insurer's decision to deny coverage for an item or service. Some claims may be denied coverage due to the evolving nature of many drug therapies.
Use the information below as a reminder when filing an appeal:
- Coverage decisions may be made by an insurer before the treatment is rendered or after a claim is filed. Coverage decisions that are made before a treatment regimen is initiated are often referred to as “Prior Authorizations,” “prior authorization” or “coverage determinations.”
- Medicare Part B and many other health insurers will not make a coverage decision regarding individual patients before a claim is filed; coverage is considered only at the time a claim is presented for payment.
- The billing provider can usually appeal an insurer's decision to deny coverage for a claim. Appeals are almost always subject to timeliness requirements; the window of time allowed for a provider to appeal an unfavorable coverage decision usually begins on the date a claim was adjudicated (processed) by the insurer.
- If the health insurer approves an appeal, you will be notified and the claim will be reconsidered. If the health insurer denies the appeal, contact Destination Access for further assistance at 1-800-861-0048.