Denial Letter, Now What?

Receiving a denial letter can be frustrating, confusing, and even frightening—especially when that letter refers to a health-related request submitted by your doctor on your behalf. There is a silver lining to this seemingly negative experience; it typically offers a better, safer, or more cost-effective solution for you.

As a patient in the U.S. healthcare system, you are empowered to take part in the choices and decisions about your medical care. As such, when a denial occurs, you are encouraged to review the determination letter you received by mail, to understand why the request was deemed inappropriate and what options are available to you now. Your health plan may suggest a more effective, less invasive, or in some cases less expensive procedure or treatment in place of the one originally requested by your primary doctor or specialist. Together you and your doctor should consider the alternative options so you can make an informed decision about the next steps in your care.

A request might be deemed “inappropriate” for a variety of reasons—and it doesn’t always mean that the plan won’t cover your care.

1. Sometimes a less-invasive option is available to try first
2. Sometimes an alternative procedure or treatment based on evidence-based medicine has been proven to provide a better outcome.

In some cases, a brief conversation between your doctor or specialist and the physician at EviCore working your case on your behalf will be all that is needed to reach a better-informed decision. In other cases, a formal appeal may be necessary.

To read more about understanding the reasons for a denied request and the options that are available to you, visit www.evicore.com, or access our FAQs here.