Here are some steps to consider if your insurance company initially does not allow coverage for your medical care at Memorial Sloan-Kettering.
- Become educated about your insurance plan -- know the type of coverage it provides and the reasons that your coverage is being denied.
- Learn about your illness and the recommended treatment options. Ask your Memorial Sloan-Kettering doctor if the recommended treatment is available only at Memorial Sloan-Kettering.
- Write an appeal letter and follow the process for filing the appeal as outlined by your insurance company. Organizations such as the Patient Advocate Foundation (www.patientadvocate.org or 800-532-5274) offer guidelines for writing letters of appeal. You can also find sample letters of appeal on their Web site. Search on "Appeal Letter" from the home page of the Patient Advocate Foundation's Web site to find this information.
- Ask your Memorial Sloan-Kettering physician to contact our Case Management Department for added support, or you can contact the Case Management Department directly at 212-639-3111.
- Speak with your employer to request they discuss the situation with the insurer.
- Speak to your union management and ask that they advocate on your behalf with both your employer and the insurer.
Remember to keep copies of all correspondence and notes of telephone and in-person conversations.
Your Legal Rights
You have the right to challenge any decision made by your insurance company that denies you coverage. Call your state Department of Insurance hotline to file a complaint.
The New York State Insurance Department's new health complaint ranking shows that consumers are winning their appeals more than half the time.
If your health insurance plan denies you access to Memorial Sloan-Kettering, you may want to consider taking one of the following steps:
File a Grievance or Appeal with Your Health Insurer
HMOs and insurers with a managed care contract are required by law to have a grievance procedure. Refer to the member handbook of your health insurance plan, or contact their Member Services Department for information on their formal grievance and/or appeal processes.
A grievance can be filed for any decision except one concerning medical necessity. (An "appeal" is the process used to challenge a finding of "medically unnecessary;" see below.)
Examples of complaints that can be challenged through the grievance procedure include, but are not limited to, the following:
- You are denied a referral to a specialist or other provider
- You are denied coverage because a benefit is determined not to be covered under your subscriber plan
- You are denied coverage or receive only partial coverage for a prescription drug
- You are required to pay a specialist fee beyond the standard co-pay
- You are denied a referral outside the HMO's network of physicians
- Your hospital stay is curtailed
By law, you have the right to file grievances by phone concerning benefit decisions or referrals, and insurance plans are required to have a toll free hotline for grievance calls.
You have the right to have any grievance decided within 48 hours if a delay would increase the risk to your health. This is to ensure that your health is not endangered.
An appeal can be filed if the HMO or insurer refuses to cover care it considers to be medically unnecessary.
You have the right to have your appeal of such denials reviewed by clinical reviewers (not financial reviewers) to make sure that these decisions are in the best interest of your health.
You have the right to appeal this decision quickly (an expedited basis) if you are currently being treated or your health care provider believes an immediate appeal is warranted. Expedited appeals must be decided within two business days.
Examples of procedures and services that could be challenged for medical necessity include, but are not limited to:
- Bone marrow transplant
- Magnetic resonance imaging (MRI)
- Breast reconstructive surgery following mastectomy
- Mammography
- Artificial limbs and other prosthetic devices
- Biopsy
File a Complaint with Your State's Department of Insurance
Within New York State, consumers who are unable to resolve problems with their HMOs and insurers can file a complaint through the following channels:
- For standard plans, contact the New York State Insurance Department Consumer Services Bureau at 800-342-3736, or by visiting their Web site.
- For managed care plans (e.g. HMOs), contact the New York State Department of Health Managed Care Hotline at 800-206-8125, or by visiting their Web site.
The New York State Department of Health has regulatory oversight of the grievance and appeal processes under the New York State Managed Care Law.
