Insurance Appeals

The MAGIC Foundation offers assistance with EXTERNAL APPEALS ONLY to current members of The MAGIC Foundation. Below is information to assist you through the insurance appeals process.

 

Frequently Asked Questions

 

Q. I am so confused and just do not understand my prescription drug benefits.
A. Navigating your prescription drug benefits can be confusing! Are you looking to better understand how prescription drug benefits work? If so, click here for a complimentary guide that should answer all your questions.

 

Q. Do you struggle with being able to afford treatment for Pediatric Growth Hormone Deficiency?
A. Click here to download a discussion guide that will help you start the conversation with your doctor about cost-saving treatment options.

 

Q. What do I do if my Prior Authorization has been denied?
A. Consult your doctor as soon as possible and they will file the necessary paperwork.

 

Q. How do I get interim medication?
A. You should be assigned a caseworker from the manufacturer of the chosen medication to aid you and the physician in this process. Make sure the physician is aware you wish to receive medication while beginning the appeal process so that all forms are filled out correctly. 

 

Q. Is there any help with co pay assistance?
A. Click here for a list of programs that may be able to assist

 

Q. Does my insurance cover growth hormone?
A. In the "Medical Policy" section of your insurance packet it should describe what types of growth hormones are covers and for which diagnoses.  

 

Q. What criteria/testing does the insurance need for approval?
A. You or your Endocrinologist can find this out by speaking with your insurance company. 

 

Q. Where can I go for help with the external appeal?
A. The MAGIC Foundation has a fantastic program to help guide you through the steps in the External Appeal Process. This is usually the final step in the appeal process.  This appeal is usually done with the state or outside third party. The doctor usually will not help with this step as it is very time consuming. The MAGIC Foundation is a great resource to aid you in hopefully reversing the denial!

 

Understanding the Appeal Process

 

Your doctor’s office will send a prior authorization request to your insurance company for medications before sending the actual prescription to be filled. Your insurance company will either approve or deny the request within a short period of time (typically 24-48 hours). When prior authorization for the patient is denied, the appeals process begins. Depending on your insurance company and the specific rules that have been established for that particular plan, a member may have the opportunity to appeal one, two or three times. The member should review their insurance plan guidelines to find out how many appeals will be allowed.

Become familiar with your state’s laws and Insurance policy & the insurer’s guidelines.

  • Laws – Some states have laws that define medical necessity and have standards for HMO plans to abide by. These state laws are commonly referred to as statutes and can be accessed on your state’s website.
  • Deadlines – An appeal is allowed a certain amount of time to be filed. It is critical that an appeal is submitted within the amount of time allowed by the insurance company. The denial letter includes the number of days that an appeal must be filed by.
  • Exclusions – Review your actual policy in order to confirm that the treatment you are seeking approval for is or is not covered.
  • Self-funded plan vs. fully insured plan – Check with your human resources office to find out which plan you have. Those with fully insured plans have the option of an external appeal, which is independent of the insurance company, typically submitted directly to the state. Those with self-insured plans have the right to an external appeal however it is submitted directly to the insurance company, which then gets forwarded to a third party reviewer. The employer has the ability to override the adverse decision.
     

CLICK HERE FOR SAMPLE APPEAL LETTERS

(Membership to MAGIC is required to access sample appeal letters. If you are a member, just login with your email and password after clicking above link)

 

Follow up procedure

 

If all internal appeals have been denied and you wish to request assistance from The MAGIC Foundation for your external appeal, please fill out this form below and someone from MAGIC will contact you.  Please know that external appeals are very time sensitive and due to an overwhelming amount of requests, we may not be able to assist you.

 

 

 

 

Patient Assistance Programs

 

There are a number of patient assistance programs and co-pay assistance options available. Please check them out to see if you qualify for any assistance.

 

 

"The MAGIC Foundation has been a HUGE blessing to our family. During a time when we continually were experiencing lack of support or avenues to venture down, we came across MAGIC. After hearing so many, I'm sorry I can't help you... or your daughter doesn't qualify... It was refreshing to hear a friendly, warm, reassuring voice on the phone who was optimistic and open to help. It almost felt unreal, but it wasn't! Without the support of the MAGIC Foundation, our precious little daughter wouldn't have been approved for growth hormone therapy. The Insurance Appeals Specialist from MAGIC really went to bat for our family and was by our side the entire way through. She was even present on the telephonic hearing call which was held with a judge and several opposing individuals from insurance companies, which literally meant the world to me! We can not fully express the gratitude and appreciation for what the MAGIC Foundation provides to families like ours. Thank you, for all that you have done and continue to do! It really matters and makes a world of difference to our little children. God bless you all!"               B. Ma, California

 

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