Sample Appeal Letter
Sample Appeal Letter – 62 page guide – DOI Washington State

The process of

appeals & grievances

gets very technical, legal, etc.  I won’t even attempt to summarize it here.  Please follow the links below, check your policy – evidence of coverage and check the law.

Medical Procedures?

Was your procedure Medically  Necessary?

Blue Cross Clinical UM (Utilization Management) Guidelines,

Did you use the Correct MD or hospital – Provider List and

Did you Review the procedures in your actual policy, evidence of coverage?

Here’s a sample Speciment EOC Evidence of Coverage – Platinum Plan Page 151

 

 

Reasons why the Claim might be denied

Did you tell the truth on your application?
How does the Insurance Company know, if the application wasn’t filled out correctly?
Here’s where they write to your MD, before a claim is even turned in.

Billing Codes – Satire or how it really works?
 

 Consumer Links

Maytag Repairman
Maytag Repairman
Gather documents, cancelled checks, warnings, late notice, emails, phone logs
Gather documents, cancelled checks, warnings, late notice, emails, phone logs

 

Please note that under Health Care Reform – Waiting Periods and Pre-X pretty much are not there!

 

Navigating the Appeals Process - Patient Advocate Foundation
Navigating the Appeals Process – Patient Advocate Foundation
eoc.complaints
Specimen EOC Evidence of Coverage – Appeals – Grievances
Understanding what you pay and when

Grievance procedures Free Advise.com

Insurer’s Bad Faith

Free Advice.com WHAT IS THE APPEALS AND GRIEVANCE PROCESS LIKE?

Blue Cross Specimen Policy – Sample Appeals Procedures Page 151

How to gather documents to prove your case – Small Claims Manual

Prove you never got a letter?

How to create a TIMELINE in Word, Excel, PowerPoint

Fines against PacifiCare for improper claims handling 1/30/2008 CHFC

Health Net faces suit over refusal to cover treatments LA Times 9.13.2012

Appeal Guide – Washington State 62 pages pdf

Todd Friedman, Esq. can help if debt collectors are harassing you when you don’t owe the $$$

Insurance Company & Regulatory Agency Grievance Procedures & Forms

Kaiser, & Blue Shield Grievance Forms

Aetna

Blue Cross Grievance Procedures

Notice

Blue Shield – General Info.  Appeals & Grievances  PO Box 629007  El Dorado Hills , CA 95762 – 9007  Fax: (916) 350 – 7585

CA Department of Insurance  

IMR – Independent Medical Review  

   

Enforcement

Anthem Blue Cross Fined $415K since the California Department of Managed Health Care said it found 40 cases in which Anthem deprived members of their grievance and appeal rights. –   CA Healthline 5.3.2016

 

Other Pages in Appeals & Grievances Section

Medicare Appeals & Grievances

Insure Me Kevin.com

Historical

Blue Cross Summary 6/2011 on how Health Care Reform mandates will be complied with

Blue Cross Anthem Summary 10/22/2010

Anthem Blue Cross Fact Sheet

3 comments on “Appeal & Grievances?

  1. I STARTED a POLICY ON FEB 1 EFFECTIVE DATE AND [I] CANCELLED MY POLICY DUE TO UNHAPPY SERVICES ON MARCH 2

    THEN WHY DO THEY WAIT TO TERMINATE ME UNTIL APRIL AND DO NOT GIVE ME A REFUND OF MY MONEY .

    • 1st off, you probably upset the Insurance Company, using all caps in your correspondence with them. Net Manners.com

      2nd I had to read your email several times and do major edits before I could understand your question.

      3rd – I don’t know what kind of a policy you are talking about.

      I will assume it’s individual health insurance. In our speciment policy page 22 it says that the agreement is monthly. Thus, when you cancel on March 2nd, you are covered for the rest of March and the policy can cancel the last day of March, NOT March 2nd.

      See also the explanation of Monthly premiums on page 32.

      See page 34 on the effective date of termination, which clearly says termination is the last day of the billing period that your termination was received.

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