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When benefits are denied: The appeals process

If the patient is denied coverage for care that his or her healthcare providers deem to be medically necessary, you may decide to file an appeal. If you do, evidence-based documentation about the care plan (the documentation collected on behalf of the patient up to this point) will be useful to include in the appeal.

Generally, this is how appeals processes work. When claims or requests for services are submitted to an insurer, they first go to a utilization-review manager or claims manager at the insurance company. This person is the first to handle the claim. Sometimes a legitimate claim for treatment may be denied because the insurance claims person initially handling the claim does not understand the nature or complexity of bulimia nervosa. It's not uncommon for patients seeking treatment to encounter problems getting insurers to pay for part or several components of the treatment plan. Insurers may initially decide

  • not to pay for the level of care recommended;
  • not to approve the full number of days of treatment that the healthcare providers recommend;
  • not to pay for care at a facility the patient wishes to receive treatment at;
  • not to apply medical benefits to treat physical symptoms of a mental diagnosis and instead apply the mental health benefits to medical treatment.
Sometimes, insurers also may use body mass index as an indicator of recovery, even though clinical evidence does not support this measure as a valid outcome measure for determining recovery from bulimia nervosa.

Although insurers cannot be forced to increase benefits, the patient or his or her designated advocate (see Confidentiality issues) can work with the insurer to optimize how the available benefits are accessed and applied to the situation. Claims advocates at treatment facilities we contacted advise that if claims are denied, the patient has nothing to lose by filing an appeal and may obtain some additional benefits. If an appeal is filed, an insurer is required to provide beneficiaries with specific information on how the appeals process works. That information includes who the beneficiary should send the appeal to, the documentation needed to support the appeal, and the length of time it will take the insurer to respond. Check the insurer's Web site for this information or talk to a customer service representative in the insurer's claims department.

Claims advocates recommend that any appeal letter written on behalf of the patient clearly state the issues and provide evidence to support the treatment requested in the context of "medical necessity." They recommend including physician letters about why the patient needs the treatment for medical/psychological health and the likely consequences to the patient's health of not receiving the treatment recommended. This is where clinical evidence, careful documentation, and letters from healthcare providers can substantiate an appeal. Claims advocates say that appeals that are well stated, well organized, and include appropriate documentation are more likely to be approved. Tips for the appeals process and the checklist can help you through this process.



  
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Bulimia nervosa is an eating disorder in which a person engages in binge eating (eating a lot of food in a short time) followed by some type of behavior to prevent weight gain from the food that was eaten. This behavior can take two forms: self-induced vomiting, misuse of enemas, laxatives, diet pills (called purging) and excessive exercise, fasting, or diabetic omission of insulin (called non-purging). Some people with bulimia nervosa may also starve themselves for periods of time before binge eating again. Bulimia nervosa has important mental, emotional, and physical aspects that require consideration during treatment.

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