Below is a sample insurance appeal letter. In Texas, there is an insurance mandate. This appeal letter is based on a specific situation. Please do not take this as legal advice.
Policy Holder's Name
Member I. D. # _________
Policy Holder's Address
Date
Claim Review Section
Blue Cross and Blue Shield of Texas
P. O. Box 660044
Dallas, Texas 75266-0044
Re: Appeal to Denied ABA Therapy Claims and Coding of ABA Claims as Out of Network; Letters from Blue Cross Dated _____ Denying Applicability of Texas Autism Mandate
Insureds: __________(Name of Child), born ____, and _________ (Name of Second Child), born ________, my children, both of whom have autism.
In Texas, autism services, including applied behavior analysis are essential benefits under the state's Affordable Care Act benchmark plan. All policies sold through healthcare.gov. must provide coverage for autism services. According to Texas Insurance Code Annotated Section 1355.015, with proper documentation in the form of a letter from the primary care physician, certain types of therapy, including ABA therapy, must be covered. Beginning on September 1, 2013, the age cap for autism services was removed completely. However, children with autism who are age ten or older get a maximum of
$36,000/year in autism services. There is no dollar limit on autism services for children under age ten.
Please see the following references for further clarification:
http://www.tdi.texas.gov/hmo/documents/manhealthben.pdf --Texas Department of Insurance document stating that autism benefits are mandated for all individual plans, small employer plans, and large employer plans, including all new policies sold through healthcare.gov.
http://www.cms.gov/cciio/resources/data-resources/ehb.html--Centers for Medicare and Medicaid Services information on benchmark plans for the states.
http://www.autismspeaks.org/sites/default/files/docs/gr/ehb.10.18.pdf--Autism Speaks document clarifying coverage requirements under the Affordable Care Act. Coverage is required in Texas.
http://www.autism-society.org/in-the-news/autism-insurance-laws-whats-changed-what-hasnt-understanding-the-affordable-care-acts-impact-on-autism-treatment-coverage/--Autism Society document clarifying coverage requirements under the Affordable Care Act. Coverage is required in Texas.
A letter from the primary care physician providing the diagnosis of autism is already on file for each of my sons. These letters were written and submitted to Blue Cross before either child reached the age of ten.
The policy for the boys, _________(Name of Policy), was purchased at healthcare.gov and began on January 1, 2014.
I tried to fix some of the claims earlier by calling customer service, but the matter did not get fixed, and I am sending this letter in order to preserve my appeal rights.
Claim Dates with EOB Errors for Services Performed at ________(Name of Facility):
(List in chronological order. This information is easily found by logging in at bcbstx.com).
NPI for _____(Name of Therapist), Board Certified ABA Therapist, ________(Name of Facility): ______
NPI for _____ (Facility): ______
(NPI numbers, identification numbers for providers and facilities, can be found by Googling on the net or in the insurance company's provider finder.)
_______(Facility) is sometimes being coded as "out of network," when it is "in network." The behavior therapist at ______ (Facility) is also "in network."
_______ (Provider or Facility) contacted Blue Cross again on _____(Date) and spoke to _____(Customer Service Rep's Name), BCBS reference number ______. _____(Customer Service Rep) from Blue Cross told _____(Provider or Facility) that_______(Provider or Facility) was in network and the claims were being filed properly by ______(Provider or Facility). _____(Provider or Facility) asserts that errors are being made by Blue Cross.
Therefore, the above claims were rejected in violation of Texas law.
Note: The family's yearly deductible and out of pocket maximum of $_____ were met before these claims were filed, so everything should be 100% covered. We have a subsidy through ACA.
Further note: Additional claims are expected from the above provider.
Thank you for your assistance.
Sincerely,
Your Name
Your Phone Number
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