Through research and experience, Fertility Within Reach has developed steps to increase the effectiveness of your communication with insurers, employers, legislators, and clinicians. Organization and evidence are critical to helping you become a better advocate and confidently communicate. Check out our videos and guidelines below.
Upon request, your employer or insurance company should provide you with a copy of your insurance plan, including the specific language regarding your benefits and coverage.
Record the names, dates, and details of any discussions with a representative from your insurer. You may need to rely on this information later on in the case of a denied claim or appeal.
To best understand the options available to you and to discuss those with your insurer, develop a personal medical record to document your past diagnoses and treatments.
Check to make sure that your pre-authorization requests include accurate patient information. You can also ask your doctor or clinic to double-check diagnosis and procedure codes for accuracy in billing.
Upon receiving a denied claim, ask your insurance company for written information on how to appeal a decision on a claim.
Often times you may only have a limited time from the date you had the procedure to get an appeal underway – in some cases, as few as 60 days. Act quickly to ensure your appeal is received in time.
You can file an internal appeal of an insurance denial or request an exemption of benefits
Before you can appeal for the decision to be overturned, you must understand why the claim was denied in the first place. Contact your insurance provider to be sure you have been notified of all of the specific details associated with your denial.
Get a copy of the denial letter. Request an explanation of benefits and/or policy booklet from your insurance provider. If you were denied based on insurance guidelines, you can request what research their guideline was based on. Ask your doctor if there is more current research to counter their denial. Arm yourself with their materials to help you prepare for your appeal. This will allow you to use their language and process that can save you time and energy.
The insurer must provide you with when and where the appeals must be sent, as well as what information must be included within an appeal. Your appeal is more likely to be considered if you follow their process.
Once you have a strong understanding of the reason for denial, you must determine your strategy. Will you appeal on the grounds that this treatment is in fact supposed to be covered through your existing plan? Use language from your plan to support your claim. Were you denied coverage because it was not deemed medically necessary? Ask your doctor to write a letter on your behalf explaining why this is the best medical treatment plan for you.
Your appeal must include all background information regarding the specific claim. This includes your claim and policy number, your date(s) of service, your health provider information, etc. The insurance company cannot overturn a decision if they do not know the decision in question.
Use the same terminology as the insurance provider throughout your appeal, especially when stating why their denial should be overturned. You can often refer to your benefit or policy information and use their wording against them.
When drafting an appeals letter, share a short personal paragraph to make your letter memorable. However, you must include as much factual information as possible. An insurer will consider the facts of your situation and compare them to what is included in your policy.
State the resolution you are seeking in measurable terms. For example, you may ask for full coverage for 2 cycles of IVF. In addition, you can inform the insurance provider of what next steps you are prepared to make should they uphold the denial. For example, you can relay if you pay out of pocket, you will make medical decisions, such as how many embryos to transfer in an IVF cycle, based on financial concerns.
It is important to attach as much supporting information and documentation as possible to your appeal. Remember that there are doctors reviewing these claims. Include studies, facts, and even letters from your own doctors supporting your appeal.
It is helpful to the claim reviewer to have all of your information in one place. Send a complete package including a cover letter listing each of the pieces of documentation, your appeal letter, your relevant medical records, a letter of medical necessity from your doctor, etc. Keep a complete copy for your records so you can reference as needed in follow up phone discussions.
Send your appeal via certified mail. This will stop you from questioning when it got there. In addition, follow-up with your insurance provider within 10 business days to ensure they received the package. In addition, at that time, confirm with the provider they have received all pages of your package so you can be sure they have all of the pieces of the puzzle.
Though this can be expensive, an attorney or patient advocate in your area may have other strategies to support the appeal process. Some are willing to do so for a small fee or pro bono, so it is worth reaching out.
Your employer selects your insurance company and if you are not satisfied with the services, you can reach to your employer to determine if other plans are available.
Prior to providing the background on your situation, be sure you have the best point of contact at your employer to deal with insurance benefits. This person is normally within human resources and should be knowledgeable on your insurer.
Depending on the size of your company or the variety of available insurance plans, your human resource specialist may not know all of the specifics of your health plan off hand. To help gain their support from the beginning, it can be helpful to provide the documentation you’ve gathered regarding your plan and the specific coverage you are requesting.
Your employer will not offer the coverage without knowing the need is there. It is up to you to ask.
There is a wealth of information available regarding the reasons an employer should offer infertility benefits. Compile and share this information to show them the potential advantages of offering this coverage. Companies are competitive so you can show what comparable businesses are offering in terms of infertility benefits.
Your employer is more likely to adjust benefits when multiple employees rally for the cause. Given that 1 in 6 couples in the US are affected by infertility, chances are many of your co-workers have either been directly impacted by infertility or know someone who has. Strength builds when numbers increase!
In some cases a company, especially a self-insured company, may grant exceptions when requested by an employee. For example, if your benefits are capped at one IVF cycle but another is necessary, your employer may consider making an exception.
Download the Employers Toolkit and share it with your employer.
In your opening paragraph, introduce yourself. If you are a constituent, indicate the town or precinct where you live. If you have heard your legislator speak on an issue or met them at an event, remind them of the meeting.
Clearly, state why you are contacting them. Do you want them to support or oppose a specific bill? If so, provide the specific details (legislation number, date of the vote, etc.) and then clearly explain your argument for support/opposition of the legislation.
While it is important to get personal, you should always include evidence-based information to support your argument. Provide results of studies, examples from other states, or even testimony from experts in the field.
Legislators cannot be experts on every issue they vote on. They have a support staff to help with research and to understand the needs of their voters. Offer to provide the information you’ve already gathered to help them make their decision.
Introduce yourself and whether you are advocating on behalf of any organization or specific issue. State why you are meeting with them. Do you want to inform them of an issue or and ask them to take action on it? Provide specific details about why you are there.
Share your personal experience. Your stories, challenges, and achievements are what make the issue real and memorable to your legislator. If you have pictures or documentation that can support your story, share them.
Come armed with FACTUAL information that you can share to support your position and bolster your credibility.
Explain you are available for future discussions. Provide your contact information. Ask for a copy of their business card and ask if it is OK to follow-up within two weeks. Then do it. Legislators and staff can meet with hundreds of people each week on issues across the board. A friendly reminder will help keep your issue at the forefront.
Immediately after your meeting, send a thank you note. We recommend sending a direct electronic message which will get to your legislator’s office more quickly –and allow for easy contact.
It’s best to be yourself. Don’t hold back your emotions. If you break down, that makes the subject more real. You should dress professionally, and business casual is acceptable.
Bring enough copies of your written testimony to distribute to each committee member. Remember that the legislators are not experts on the topics and you should be prepared to answer follow-up questions. As you prepare your testimony, provide background on the issue.
Be prepared to wait to provide your testimony. You won’t know where your bill falls on the agenda. When signing in, you can request to go early and give a very appealing reason why. The hearing room will likely be filled with lobbyists, legislators, and constituents ready to do the same. For the same reason, it is important to keep your testimony to the recommended amount of time. Legislators will appreciate you respecting the process.
US Senators and Representatives raise millions of dollars to be elected to represent your voice: they can’t do their job effectively unless they hear from you. These links will take you directly to the U.S. Senate website, the U.S. House of Representatives website, as well as to our State Advocacy page with current links for each state.
Ways to make your voice heard:
Fertility specialists are OB/GYNs with additional training in advanced assisted reproductive therapies and are often called a reproductive endocrinologist. Identifying the right physician is an important step in your fertility journey. You can use a biography to learn if the experience of the doctor matches your medical need.
Do not be shy about asking your physician questions. Develop a list of all of your questions before your appointment so you cover all areas that are important to you and so you don’t forget during your visit. Questions may be about tests, treatment options, timing, and future visits.
Review your insurance policy or call their customer service to develop an understanding of what your medical insurance plan will cover. This information may be valuable in discussing treatment options with your physician.
For your physician to best be able to help you, it is important to provide him/her with medical information for both you and your spouse.
You have done your homework and documented your questions and medical history. Remember to bring it to your appointment and use it.
In dealing with infertility, it is inevitable that you will experience emotional reactions. To support you in your discussion with your doctor you should consider bringing a third party, such as a spouse or a friend, to help you ask questions, retain information, and advocate for your treatment.
The wealth of information provided by your physician can be overwhelming. To ensure you do not forget anything, write down the answers to your questions and other key information your doctor shares.
If you did not have a positive experience or connection with your doctor, it is OK to look into a second opinion. You need to be comfortable in speaking with your doctor and if you don’t, you should look to other clinics or doctors who may be a better fit for you.