Insurance Appeal Letter (mandate)

Last updated Thursday, July 26, 2012   |   comments
The letter below can be used as a model for those states that offer mandated autism insurance. If possible, get the help of a lawyer to cite supporting legal precedent relevant to your state. The more specific the better.  You can also call Butterfly Effects, and we can help review your letter to make sure it covers all your bases. The goal is always to move things along as quickly as possible


SEND VIA CERTIFIED MAIL

DATE

Claim handler’s name
claim handler’s title
name of company
claim handler’s city state zip
RE: enrollee’s name
DOB: enrollee’s date of birth
enrollee’s social security number

health plan purchaser’s name
health plan identification number

CLAIM NUMBER:

SUBJECT: Payment Authorization for Enrollee’s Autism

Dear:

Please receive this letter as a formal, urgent and continuing request for you to promptly authorize payment for those therapeutic interventions recommended by the enrollee’s treating physician as being medically necessary, now and over a period of time. (see attached physician’s letter of medical necessity)
As you can see from the physicians report, the following is recommended:
  • A full assessment with treatment development performed by a Board Certified Behavior Consultant,
  • Minimum of 25 hours per week of ABA-based intervention services delivered one-on-one in the child’s natural environment,
  • Medication treatments as needed.
While you may be well versed in the language of the health care policy under discussion, please understand that any language is superseded by the legal mandates put forth by the state regarding provision of benefits for children with autism.

Your company must comply with the stipulations of that mandate as a condition of doing business in our state. Your company had to agree to provide specific treatments for autism that are “medically necessary,” that do not discriminate based on age, and that cover an amount equal to those benefits offered “to other medical conditions.” 

In its wisdom, the state legislature has determined that ABA-based therapy is a medical necessity for children with autism. This is beyond dispute. In other words, the state legislature has conclusively determined that autism intervention does work – hence, it is not experimental and is indeed medically necessary.

Furthermore, more than three decades of medical literature also promotes the fundamental maxim that the earlier the autism intervention, the better the expected medical result: (Please read the physician’s letter on medical necessity for an extensive list of citations and references.)

Clearly, when a healthcare plan refuses to authorize autism treatment at the earliest possible moment, it fails to do what is possible to prevent significant future disability as well as failing to  alleviate severe pain caused by an inability for an individual to communicate and become a productive and independent and connected member of society.

Repeated violations of state mandates can cause your company to lose its license to do business in our state.
Because time is of the essence, I am requesting that you immediately authorize payment for all the interventions recommended in the enclosed report.

If there are any interventions for which you refuse to pay, please immediately identify those interventions and give the reasons which support your denial.

II. SIMULTANEOUS PETITION FOR INTERNAL APPEAL
As to those claims which you intend to refuse to pay, if any, please deem this letter to also be a petition for appeal of said refusal within the appeal and grievance procedures set out in your plan. Pursuant to this appeal petition, I request that you immediately photocopy and distribute this letter and its enclosures to each and every member of each and every appeal and grievance panel procedurally recognized in your plan. This I insist upon to guarantee that timely treatment remains a viable option. In other words, this should prevent your response from developing into a protracted battle of resistance that could result in an untimely treatment program that might forever injure the optional recoverability of your enrollee, my child.

Please send me a copy of this distribution list and provide me with the dates and times in which I may appear before these panels to advocate my cause.

REQUEST FOR ARBITRATION
As to those claims refused by you, which refusals your appeal panels intend to uphold, please then deem this letter to also be a request for arbitration of those refused claims. It is my desire to have an impartial arbitrator immediately hear my contention that the refused benefits are medically necessary, and hence must be provided. The above quoted general and autism state mandates, as well as the medical literature and the legislative preamble, clearly establish that the reliable autism interventions requested by me are medically necessary, and hence cannot be justifiably refused by you.

Please immediately provide me with an arbitration date so my experts can appear to establish medical necessity. This arbitration will only be necessary if you continue to deny my appeal to you to reconsider my claim.

Very truly yours,

 
 
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