The first step is making sure the denial wasn’t made in error.
Just because a health insurance company says it will pay only part of your claim, that doesn’t mean you just have to accept the decision. You have the right to appeal — as long as you do so within the prescribed amount of time — usually 180 days
of receiving a notice your claim was denied.
But first, make sure you understand why your claim was denied and what steps you need to take to
properly appeal a decision. It pays to take the time to read your policy, check your insurance company’s
website or talk to customer service to better understand what your policy is supposed to cover. You also
must understand the difference between a rejected appeal and a denied appeal.
A rejected appeal occurs when the claim could not be processed due to incorrect information.
Rejected claims do not need to be appealed. You only need to correct the error on the health insurance
claim form. Then resubmit it for the insurance company to reprocess the claim.
A denied appeal results when an insurance company does not approve payment for a specific
procedure, test, or prescription. Some reasons your appeal may be denied include:
• Your health insurance plan does not cover that particular service or procedure.
• You have exceeded the coverage limits in your plan.
• The drug or therapy is not covered by your health plan.
• You may have used out-of-network services when your health plan requires “in-network” providers.
If you believe that none of these reasons applies to your claim, you can request an internal appeal,
which will be conducted by the insurance company. If they reject your claim a second time, you can
request an external appeal conducted by an independent third party.
Internal Appeals
You should receive an explanation from the insurance company about why your claim was denied
and the steps you can take to appeal the decision.
Before calling an insurance company representative, find your policy information, the summary of
benefits and the denial letter. Prepare a list of questions. Take notes and get the name of the person
you’re talking to and the date and time of the conversation. This might fix the issue if the claim was
denied because of a simple error.
However, if your claim wasn’t denied because of error, you must write the insurance company a
formal letter asking them to reconsider the claim. Your letter should include:
• The service, treatment, or therapy that was denied and the reason for the denial.
• A request that they appeal the decision.
• The claim number.
• History of your medical condition or health problems.
• Explanation of why the treatment is or was medically necessary.
• Supporting information from your doctor, such as a letter.
• Evidence, such as medical records, X-rays and lab results.
Remember that you can ask for an expedited appeal if you or your doctor thinks the denial of your
claim is life-threatening.
Independent External Review
You can ask for an independent external review if your claim is still denied after an insurance
company internal appeal. Many states have an external review process. If they don’t, the federal
Department of Health and Human Services will oversee the review. Your explanation of benefits or the
final denial of your internal appeal should have the contact information about who will handle your
external review.
You must file a written request for an external review within 60 days of the date your insurance
company sends you a final decision on your internal appeal.