Step 3. Apply to get your transition procedure pre-approved
Once you have figured out what your plan says about transition-related care, and also if you have a self-funded plan or not, the best next step is usually to apply for preauthorization (sometimes called prior authorization). That means submitting a claim to your health plan, asking them to approve coverage before you have your procedure.
What if my plan has an exclusion?
You or your doctor should apply for preauthorization even if you think your plan excludes transition-related care.
It is possible that the insurance company may agree to cover the procedure even if they have a general exclusion of transition-related care or an exclusion to a specific procedure, especially if they get information about why the treatment is medically necessary for you.
Additionally, if they do deny the preauthorization, the plan has to send you a letter telling you why they denied it and explain your appeal options.
What if my claim is denied?
You should always refer to your plan booklet for information about your options to appeal denials of claims or preauthorization requests. For example, if you are a federal employee, you might be able to dispute the claim with the U.S. Office of Personnel Management, in addition to the insurance company.
We strongly recommend that you reach out to a lawyer or a clinic for assistance with insurance appeals, including appealing denials of preauthorization. You can also reach out to a health care advocate for support throughout the preauthorization, claims and appeals processes (you can find a list of resources here).
How can I apply for preauthorization?
You can find instructions for applying for preauthorization in your plan documents or by calling your insurance company.
What types of documents should I send?
You should always discuss with your surgeon what your plan requires for preauthorization and what you (or your doctor) need to submit to them. You will typically have to submit at least two different documents. The first one is a letter from you to your health plan. The second is a letter from your health care provider (typically a mental health or your primary care provider). Always check the plan documents for specific letter requests.
Don't know where to start? We can help! Check out the links below for templates and resources you can use.
Always remember to have in hand the specific plan policy on coverage for transition-related care to know the specific requirements that your letter and your doctor's letter should address. You can call your health plan or check your member handbook for this information.
- Template for writing a letter to your health plan to request preauthorization. This template will help you create a letter explaining why you need the treatment and why refusing to cover it might be illegal. We’ll provide you with an explanation of the law that you can copy right into your letter. The legal explanations will be particularly useful in cases where your plan has a blanket exclusion or an exclusion of a specific procedure. The legal explanations can also be useful to appeal a denial of a preauthorization or claim request.
- A guide to health care provider letters. In addition to your own letter, your health care provider should write a letter explaining why the treatment you’re seeking is medically necessary for you. Click the link for information on what the letter should typically include and resources for your provider.
- Templates for people with a self-funded health plan. This page includes information and templates for people who have a self-funded health plan.