Before You Do Anything:
Talk to your ABA provider & decide who is going to submit the appeal. Depending on the specifics of the denial, the appeal may be best handled by the provider. In some cases, however, the appeal is best initiated from the member (you!).
Step 1: Review the Denial
Find out which services were denied (e.g. assessment, treatment, specific CPT codes, or a certain number of units/hours) along with the denied dates of service. This helps you understand the scope of the denial.
Step 2: Determine WHY Services Were Denied
Read the denial notice carefully. Look for the specific reason along with the specific insurance policy quoted as the rationale for denial. If no policy is stated or it’s unclear, you can ask for more clarification by calling your insurance directly.
Step 3: Strategize With Your Provider
Discuss the reason for denial with your provider & how you will address each point. Simply saying “My child needs this care.” will not suffice for the appeal. The insurance company wants specifics and “proof”.
Step 4: Gather Supporting Documentation
Collect any/all records from your current ABA provider and/or other providers.
STEP 5: Write Your Appeal Letter
Your appeal does not have to sound like it was written by an attorney.
Clear and organized is more useful than wordy and complicated.
Step 5: Submit Your Appeal
Ensure that you submit all appeal documentation before the deadline in your Denial Notice. The Denial Notice will also outline the exact process of submission (mail, fax or phone).
Step 6: Track Status Of Appeal
Keep a record of when you submitted the appeal and follow up regularly with the insurance company to ensure the appeal was received and is being reviewed.
What happens if your appeal is denied?
Read the second denial notice carefully. The notice will contain information about the options available to you. Typically, escalation to an “external review” (where a third-party outside of the insurance company reviews the appeal) or a “fair hearing” (taking the authorization to court) will be the next step. In these instances, more collaboration between you, your ABA Provider, your Pediatrician, and others might be necessary. Follow the same steps as above, though, to complete this next round of appeals!
