Steps to Take if Denied Coverage

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. Learn the reasons why your coverage is being denied.
• Learn about your medical condition and what the recommended treatment options typically are. If you have not made an appointment at Memorial Sloan Kettering, ask your primary care physician or oncologist if Memorial Sloan Kettering offers treatment that is not available from doctors or hospitals that are in your insurance plan’s network. If you have an appointment for a consultation at Memorial Sloan Kettering, ask the doctor if the recommended treatment is unique to our Center.
• 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 (800-532-5274) offer guidelines for writing letters of appeal. You can also find sample letters of appeal on their website. Search on “Appeal Letter” from the home page of the Patient Advocate Foundation’s website to find this information.
• If you pay out-of-pocket for a consult and Memorial Sloan Kettering doctors recommend treatment or surgery that is not available in your network, ask your physician to refer your case to Memorial Sloan Kettering’s Patient Care Advocacy Program in Case Management. This program helps patients apply to their insurance companies for an exception in order to cover the costs of care to be received at Memorial Sloan Kettering. These exceptions are sometimes allowed when the treatment plan recommended by Memorial Sloan Kettering doctors is different from that proposed by an in-network oncologist or surgeon.
• Speak to your employer or union and ask that they advocate on your behalf with 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, after taking some or all of the steps outlined above, your health insurance company continues to deny 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 (on an expedited basis) if you are currently being treated or your healthcare 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 HMO or insurer 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.
• For managed care plans (e.g., HMOs), contact the New York State Department of Health Managed Care Hotline at 800-206-8125.

The New York State Department of Health has regulatory oversight of the grievance and appeal processes under the New York State Managed Care Law.