Guidelines for Filing Insurance Claims
1) Filing Initial Claims
a. Most insurance policies cover “cranial prosthesis,” but do not cover “wigs.”
b. The insurance C.P.T. code most commonly used is CTP-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” or a “Cranial 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 you 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. A Cranial Prothesis may be covered for medical reasons, though.
– 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 medical 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.