Checklist for preparing for your IVF Insurance Appeal

A denial letter from your insurance company can shatter your hopes of building your family through IVF. However, you can maximize the likelihood of overturning your insurance company’s refusal to pay with a well formulated appeal.

Here is a checklist prepared by Catherine Tucker, Esq. on some things to think about when preparing for your IVF insurance appeal:

  • Avoid arguments based on emotion; instead focus on facts, laws and science.
  • Be sure you are aware of the deadlines for your appeal process.
  • Check for errors in the information the insurance company used to make its decision. For example, a simple error in your date of birth can result in a wrongful denial based on your incorrect age.
  • Consider any applicable laws or rules, such as those pertaining to the Massachusetts infertility mandate, to determine if the insurance company is following the legal requirements.
  • Determine whether your health plan is an “insurance plan” or a “self-funded plan”.  Some employers choose to offer infertility benefits under their self-funded plans, to which the Massachusetts infertility insurance mandate does not apply. The applicable rules and procedures also differ between the two.
  • Enclose supporting documentation from your own medical file and from reliable external sources.
  • Evaluate the basis for the denial.
  • Include a supporting letter from your RE.
  • Learn about the appeals process available under your health plan.
  • Reach out to your IVF clinic’s insurance coordinator – they often have helpful insight into the process.
  • Review the insurance company’s medical policy regarding IVF coverage.
  • Tailor your appeal arguments to help the reviewer understand why the insurance company made a mistake–either in formulating its own guidelines or in the application of those guidelines to your situation–or why your circumstances require a deviation from the guidelines.
  • Understand your health plan’s infertility benefits.
  • Write an argument for why coverage will provide an overall financial savings to the insurance company or your employer, if possible.

Catherine Tucker, Esq. is an RNE Board Member and Attorney in New Hampshire. She can be reached at the Law Office of Catherine Tucker.

Comments

  1. The Massachusetts law has one statement that may be key for workers of out-of-state employers,and those commuting out of state. The law applies to, “all individual subscribers or members within the commonwealth and all group members having a principal place of employment within the commonwealth.”

    The law is attempting to regulate group plans issued in other states. Group plans are regulated based upon the state where the policy was issued. Most states do not have a mandate, so there is an immediate conflict.

    My guess is that most denials stem from this inherent conflict.

Comment Policy: We review all comments before they are posted. Any comments deemed to be abusive, illegal, disruptive or spam will be deleted at the administrator's discretion. An email addresses is required for commenting, however, they are not published on the blog, nor shared. Thank you for commenting!

Leave a Reply to Kevin @ Growing Family Benefits Cancel reply

*