It’s likely to happen sooner or later: You have a disagreement with your health plan, and an appeal is required.

Filing an appeal doesn’t have to be a daunting process. We’ll walk you through it below so you can be prepared to make the best argument to support reimbursement for your child’s treatment plan.

How to file a health plan appeal

Here are the steps you can take to address denials first at the plan level and then later within the higher level of appeal appropriate to your health plan. 

File a grievance directly with the plan. 

Filing a grievance can be done online, in writing, or by phone. Make sure you have any necessary documents and a cover letter ready to share with your health plan.

You should receive a receipt of your grievance submission either immediately online or within a few days by mail, and you should have a determination by your health plan within 30 business days.

If you don’t receive confirmation of your submission within 7 business days, you should contact your health plan again to confirm that it was received and that the 30-day timeframe is in motion.

No matter how you submit your grievance, be sure that you’re answering the specific stated reason given by the plan for denial. Take as much time as you need to thoroughly read the denial and understand their reasoning so that you can make an informed argument that addresses their contention. You want to make sure your argument addresses their specific reason. 

If the plan issues a second denial, what comes next? 

Your plan’s grievance determination notice will specify which one of three agencies that handle external appeals is the entity assigned to your plan. 

Independent medical review will be conducted by one of these three agencies:

• California Department of Insurance (CDI)

• California Department of Managed Health Care (DMHC)

• A third-party external review agency, such as Maximus

These agencies will provide you with instructions on how to submit a request for a higher level review and provide their timeline for the process to be completed.

Remember that these organizations are there to help. In the 2023 DMHC annual report, the DMHC reported a 68.6% rate of overturn of denial for Anthem Blue Cross and a 55.3% rate of overturn of denial for Blue Shield of California.

If you still don’t have a positive outcome, you may choose to go back to the third-party review agency if the plan didn’t address your contention and appeal again, or speak to an attorney to discuss the merits and costs of a legal case to compel the health plan to pay. 

Support documentation for appeals

Along with a cover letter, appeals may sometimes require progress reports, prescriptions, and letters of medical necessity. Obtain any needed progress reporting first from your child’s treating provider (their pediatric occupational therapist, pediatric physical therapist, or speech therapy provider), and then send it along to your child’s health care provider (their pediatrician or a medical specialist they work with, such as a neurologist) with any needed request for a letter of medical necessity or prescription. 

You may offer your child’s pediatrician or medical specialist a copy of the denial and a letter template that includes a header with the health plan, member date of birth, and member health plan ID number, along with a list of points you would like them to include. 

Ask them about their turnaround time for documentation, or ask if they can meet a two-week window. Be aware that there are often non-reimbursable documentation fees from both your child’s health care provider and/or the therapist.

You should also be prepared to take your child in for a follow-up medical office visit if it has been a while since they have been seen by the health care provider who will be documenting medical necessity.

Before you appeal, be sure that there’s a solid basis for you to refute the exact terms of the denial. Focus on what the plan is contending, and tell a concise and compelling story substantiated by fact that responds exactly to the terms of the denial.