The Most Common Denials:
Authorization and Non Participating Providers

Appeal Lack of Authorization or Non Participating Denials

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HMO plans usually are the most limiting in their availability of Specialists for their members.  The primary reason is that each month they pay their primary care physicians a capped dollar amount to see a specified number of members.  However, if a patient must see a specialist, the payment may come from the primary care physician's pocket, in terms of a reduced bonus or monthly payment.   Health Plans in general try to contain the visits to Specialists because their cost could be quite large.  Some important things to know about Specialists denials, include:  

  1. For most health plans, you must obtain a referral from your primary care physician.  If one is not obtained, it would be very difficult to overturn this denial. 

  2. You must also obtain an authorization where required by your health plan.

  3. Your symptoms/diagnosis required for Specialists care must be specific and detailed by your physician in your medical chart.

  4. Denials could be properly appealed depending upon the support by your physician proving medical necessity and the focus of your argument within the appeal letter.

How do you combat a denial to a specialist? The following steps may help.

  1. Review the denial with your policy booklet and verify that their denial is justified. If their reason for denial is unclear, call the customer service unit at the health plan for a more descriptive explanation. Record your conversation and document the name of the individual you spoke with for future reference.

  2. Does your health plan cover Specialist care and did you abide by the policy and limitations by the plan?

  3. Verify that the Specialist Care you sought is a covered benefit under your health plan.  If not, then you will need your physician's assistance to appeal to the health plan with a letter of medical necessity and all accompanying medical records (pathology reports, operative reports) required by the health plan to justify the medical treatment by the Specialist.