Phone script: calling your insurer about a denial

BEFORE YOU DIAL

Write down: today's date, the number you are calling, and leave space for the representative's name and a reference number. You will need all three later.

OPENING

"Hi, my name is [YOUR NAME], member ID [MEMBER ID]. I received a denial dated [DATE] for [ITEM] and I need three things from this call. First, the specific reason for the denial. Second, the plan language it is based on. Third, the deadline and address for filing an appeal. Can you help me with that, or do I need a different department?"

IF THEY GIVE YOU A VAGUE REASON

"I understand it was flagged as not medically necessary. What specific criteria was it measured against? I would like the name of the policy or coverage guideline so my doctor can respond to it directly."

IF THEY SAY YOU NEED PRIOR AUTHORIZATION

"Was a prior authorization requested and denied, or was one never submitted? If it was never submitted, please tell me exactly what my prescriber needs to send and where to send it."

IF THEY MENTION STEP THERAPY

"I would like to request a step therapy exception. I have already tried [DRUG] and the outcome was [OUTCOME]. What form does my prescriber need to submit, and what is the turnaround time?"

IF IT IS URGENT

"I need to request an expedited review. I have insulin-dependent diabetes and a gap in this therapy risks diabetic ketoacidosis, which is a medical emergency. What is the expedited timeline and how do I mark the request as urgent?"

ALWAYS CLOSE WITH THIS

"Can I get a reference number for this call? And can I have your name and extension? Can you send me what we just discussed in writing to [EMAIL OR ADDRESS]?"

AFTER YOU HANG UP

Write down: date, time, representative name, reference number, what they said, and what they promised. If they promised a callback, note the date. If it does not come, that record is what you attach to your appeal.

IF YOU GET STUCK

Ask for a supervisor. If the plan is not responding within its own stated timeframe, contact your state insurance department. If your plan is a self-funded employer plan, contact your HR benefits manager, because state regulators cannot reach that plan.