Appealing Health Insurance Denials
If you receive a claim denial and do not agree with the decision, consider appealing the denial. Go back and review the patient's insurance policy for coverage information. The explanation of benefits (EOB) letter from the health plan is the key to payment or denial status. If the coverage language supports payment, write an appeal letter describing the disorder and its medical nature, and reference the coverage policy paragraph that shows how your treatment fits coverage criteria.
Below are examples of appeal letters for speech-language pathology and audiology services. You may also purchase a copy of ASHA's Appealing Health Plan Denials, which contains sample appeal letters for a wide variety of speech-language pathology and audiology services, by going to ASHA's Online Store or calling Product Sales at 800-498-6699. Feel free to use all or part of the appeal letters when responding to third-party payers.
Speech-Language Pathology Related
The health plan may conduct an internal review of the denial. If all levels of appeal are exhausted, and you still believe your treatment meets coverage definitions, consider taking the case to the external claim review level. Currently, 42 states have an external review process (go to the Kaiser Family Foundation's Consumer Guide to see each state's procedure and contact points).
Letters Sent by ASHA
The following are examples of letters sent to health insurance companies by ASHA.