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How To Appeal Denial Of A Referral To A Specialist Or Facility Outside the Network


In order to justify why an insurer should cover a referral to a specialist or facility outside of the company's network, you have to prove that you cannot receive the care you need in network.

Work with your referring doctor to create the case. Preferably, your doctor will write the letter to the insurer explaining the situation.If the doctor refuses, at least ask the doctor to write a letter whih summarizes the medical aspects, including that there is no in network specialist or facility will work for your situation. 

The letter to the insurer should include:

  • Your general health condition and current state If past tests or treatments are relevant, include them - as well as the results.
  • Why it is "medically necessary" for you to be referred to the subject kind of specialist. The definition of "medically necessary" differs from insurer to insurer. Check your health policy for the exact wording. (Note the page as well so you can cite it in your appeal letter).
  • Explain why no specialist or facility, as the case may be, in the insurer's network is appropriate in your case.
  • Explain why the out-of-network specialist or facility is necessary for your care.
  • Describe what will happen if you don't see the specialist or attend the facility. For example, your health will be seriously impaired with attendant unnecessary medical expense and possibly death. (The idea is to explain to the insurer why it is in its financial interest to permit the requested care).

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