1) Filing Initial Claims
A. Most insurance policies cover “prosthesis” but do not cover wigs.
B. The insurance C.P.T code most commonly used is CPT-ORN-1.
C. Get a letter and/or prescription from your doctor.
D. Make sure that the letter or prescription is for a “Hair Prosthesis”
E. It should NOT say wig- if it does have it redone otherwise your claim will probably be refused.
F. Have a receipt from the person you purchased the hair prosthesis from.
2) Waiting for your claim to be processed (prepare yourself for having your claim denied)
A. Know your rights as the insured party.
B. Obtain a copy of your FULL contract with your carrier (most of us only have a “Summary of Benefits” provided by the employer.
C. Read and know your contract
· Pay attention to the “exclusions”. Wigs are excluded for cosmetic reasons.
· Pay special attention to the prosthesis coverage. Most policies do not spell out exclusions under prosthesis, and this is how you are likely to have your claim accepted.
3) Submitting your appeal (after denial of claim as “not a covered benefit”)
A. Write asking for a review by the Medical Review Board.
B. Attach copy of original claims.
C. In your letter inform them of the differences between a wig and prosthesis. (A wig is a fashion item not a necessity. Prosthesis is a necessity comparable to plastic surgery for a burn victim.)
D. Ask for a written reply. (Companies try to avoid putting anything in writing.)
E. Address your letter to a supervisor in the Claim Department.