Guidelines for Insurance Appeals Process

Denials can be a frustrating and confusing aspect of obtaining mobility equipment. Numotion and your clinical team work hard to avoid denials, but they do happen. When you receive a denial letter, as your mobility provider, we receive it too and we immediately get to work to address the situation.

Our Denial Management Team, which includes highly experienced clinicians, is your advocate and is going to bat for all our customers every day as we undertake thousands of authorization denials each year.  We check denial status daily on all pending authorizations and will move quickly to engage our expert team to work towards resolution on your behalf.

While there is high variability in how to best proceed after a denial, this document was created to give you some insight into the process and what you can expect.

Denial Reasons:

There are several different reasons that a submitted authorization request is denied. They typically fall into three main categories.

1. Non-Covered item: your insurance does not pay for the item(s) requested.
2. Technical issue with the prior authorization: your insurance company requested something additional, such as a document, a justification on a line item, a signature, or a missing date.
3. Medical necessity lacking: the justification does not meet the criteria established by your insurance. In this instance, if denied for one aspect, your entire claim is denied.

Numotion Actions after Initial Denial:

• Non- Covered: Numotion will reach out to you as soon as the denial is received outlining any non-covered items.  You may not appeal this further. At this stage your options include:
  • Purchase from Numotion for cash with a signed waiver form which allows us to accept a cash payment from you.
  • Purchase from a supplier who does not receive Medicaid, such as Numotion owned SpinLife.com. No waiver is required.
• Technical: Numotion will work with your PT/OT, MD and/or with our internal experts to obtain the additional requested information and will resubmit prior authorization on your behalf.
• Medical Necessity: Numotion’s Denial Management Team will review your denial letter and collaborate with the clinical team to gather any additional documentation needed to meet your insurance guidelines.

Denial Response Types:

There are two possible methods to respond to a denial. Understanding your rights under your policy is critical but this is where Numotion’s experience and expertise really kicks in. Our dedicated Denial Management Team will immediately begin to work the process on your behalf. To determine the timeline please review the denial letter you received.

1. Resubmission: Your insurance will allow Numotion to obtain the necessary corrections and resubmit the authorization for reconsideration. No action is necessary from you.
2. Appeal: Different insurance can have different levels of appeals and requirements for appeal. The denial letter provided by the payer will list the appeal option(s) available and who must submit it. The following options may be provided:
   • First Level Appeal: typically, must be filed within 60 days. If the first level appeals is denied, it may proceed to a second level appeals and/or one of the following.
     • IRE (Independent Review Entity): Automatically initiated for MCR/UHC plans after the first appeal decision
     • Peer-to-Peer Review: Your doctor discusses the denial with the payer. Note, this is not always the best option, and you should consult with Numotion experts before pursuing this path.
   • Second Level Appeal: typically, must be filed within 60 days. If second level appeal is denied, the following may occur depending on your specific circumstance.
     • External Review: for commercial plan, the denial letter specific who must submit the appeal
     • OMHA (Office of Medicare Hearings and Appeals): For UHC/Medicare only; involves an administrative law judge or attorney adjudicator
     • Fair Hearings: Often available for Medicaid; customers must request these directly.
     • ASO Plans (Administrative Service Only): Customers may need to contact their employer if services are employer-funded rather than covered by insurance.
   • Reconsideration Option: Some payers require a new submission with updated documents.

In appeal many payers require Numotion to obtain the Appointment of Representative (AOR) Form which allows Numotion to appeal on your behalf.  The AOR form is typically included in your denial letter, but Numotion will provide a copy if needed. If required, this needs to be signed/dated and returned promptly to Numotion.

Helpful Things You Can Do:

• Numotion is advocating on your behalf and there is nothing you must do, but in some circumstances, it can help for you to call your insurance to advocate for your denied equipment in the case of a Medical Necessity denial.
• If you have an ASO insurance plan, you may need to contact your employer if the services are funded by your employer rather than being covered by the insurance.

Options if the Appeal Is Upheld (still denied):

• If your insurance offers the option for a hearing, Numotion will determine and communicate the appropriate process to you.
• Your Numotion ATP, your clinical team, and you will discuss potential equipment changes that are still beneficial for your mobility and independence but will meet your insurance requirements for coverage.
• Numotion will collaborate with your PT, OT, MD, and/or with our internal experts to gather any new or additional documentation and, once the appeal timeframe has expired, will submit a new authorization request to your insurance provider on your behalf.

Download our Guidelines for Insurance Appeals here.