Wrong site of service

What it means

Your plan does not dispute that you need the service. It disputes the place. Examples are a hospital outpatient department instead of a doctor’s office, a hospital instead of a surgery center, or an infusion center instead of your home. The plan says a lower-cost setting is available and safe.

That is a decision about the health care setting, which the federal rules treat as a medical judgment. The plan has to explain its clinical reasoning as it applies to you, or say that the explanation is free on request. If it relied on an internal guideline, it must give the guideline or say a copy is free on request.

Who has to act first

Your doctor’s office and you. For a service that has not happened yet, a prior approval request is decided within 15 days (the plan can extend once by up to 15 days), or within 72 hours if urgent. A physician who knows your condition can say it is urgent, and the plan must treat it that way. If the plan had approved a different site first, see the approved-then-denied guide.

For a job-based plan or a non-grandfathered individual plan, you have at least 180 days after you receive the denial notice to file the first appeal; your plan may allow more. Medicare, Medicaid, TRICARE, Veterans Affairs and federal employee plans have different, often shorter, deadlines. Check the date on your notice, which controls.

Arguments that work

• Medical reasons for this setting. Heart or lung disease, a history of reactions, the need for monitoring, anesthesia or emergency backup, complex anatomy, or a long travel time to the alternative. Your records and your doctor’s letter must name them.
• Ask for the criteria. Request the plan’s site-of-care policy and compare each condition to your record.
• The alternative is not available to you. If the cheaper site is out of network, too far, or cannot do the procedure on you, say so with specifics.
• A qualified, independent reviewer. The appeal must be decided by someone other than the first decision-maker, with a health professional of appropriate training consulted who was not consulted before.
• A peer-to-peer call. Ask your doctor to request a call with the plan’s reviewing doctor before or alongside the appeal.

Evidence to gather

• The denial notice and the prior authorization request and decision (you and the doctor’s office).
• Records of your conditions and past reactions (your doctor).
• A letter from your doctor on why this setting is needed for you (your doctor).
• The plan’s site-of-care policy (the plan).
• Details of the alternative site, if the plan names one (the plan).

What to send

Send a written appeal with your doctor’s letter and records, using the medical necessity appeal letter. Ask for the decision in writing. If the plan upholds the denial and your plan is not grandfathered, you have at least four months after that final denial to request external review.

When this is not worth an appeal

If your doctor agrees the cheaper site is safe and convenient for you, switching may be faster than appealing, especially if your care should not wait. Ask your doctor first. If you switch sites, the dispute about the original site usually ends because that service is no longer being requested. If you want to keep the appeal, file it before you switch, and watch the deadline on your notice.