How To Appeal Denied Health Insurance Claims

What to Do When Your Health Insurance Company Denies Your Claim

When you want medical attention, the last thing you want to worry about is whether your health insurance will cover it. Unfortunately, a provider may refuse your claim for a variety of reasons. So, what happens next?

The good news is that a claim denial is not final. Your insurance company is required by law to explain why they did not pay your claim, and you have six months to file an appeal. Best of all, we're here to empower you with all the information you need to increase the likelihood that your insurer will overturn its decision. Continue reading for our advice on what to do if your health insurance refuses to pay for a medical service.

Find Out Why Your Health Insurance Claim Wasn’t Paid

Before you may challenge a refused claim, you must first understand why it was denied. The following are the most common reasons:

The claim has errors. As infuriating as it is, a minor error could be the source of an unpaid medical bill. For example, a provider may incorrectly code the submission, leave information out, misspell your name, or enter your birth date incorrectly. These may appear to be minor details, but if any of your information does not match the health plan on file, your medical claim will be refused. If you discover an error, request that your provider amend the information and resubmit it.
You used a provider who is not in the network of your health plan. Many plans only cover providers and facilities that are part of their network. Your supplier may not cover the charges if you leave the network. Other plans may only cover a fraction of your out-of-network expenses, leaving you responsible for the remainder.
Your treatment was not covered. Similarly to the preceding explanation, your health insurance policy may only cover specified procedures. Cosmetic operations, such as plastic surgery, are almost generally considered elective and hence not insured. Fertility treatments are only covered in some states, and even then, insurance might deny coverage due to loopholes.
Your service provider should have received authorization ahead of time. Pre-authorization is usually required for procedures such as an MRI or certain operations. If your claim was denied because it was not pre-approved, contact the doctor who ordered the operation. They may be able to present patient records to demonstrate that you required the service.
Your claim was sent to the incorrect insurance carrier. If you're married, you can have two health insurance policies: one from your employer and one from your spouse's employer. In this situation, the provider may have billed the incorrect company. This can also occur if the provider has outdated information as a result of a change of insurance. Contact your provider to find out what's going on, or verify your EOB to see if it's from the correct health plan.

Once you know why your claim was denied, you can immediately correct the situation by contacting the appropriate person—either your medical provider or your insurance agent—for assistance before resubmitting the claim. Otherwise, you can go to the procedures listed below.

Gather Your Evidence

When you contact your insurance provider about the refusal, make sure you have all of the essential documentation to demonstrate that the services you want covered are medically necessary. This can include referrals to specialists, prescriptions from your doctor, and other pertinent medical history information that can serve as proof that your claim should be reimbursed. It will also be necessary to cite the medical policy bulletin or guideline for the therapy you received from your medical plan. Both of these can be found on the website of your health plan.

Submit the Correct Paperwork

Your health plan's explanation of benefits will explain how to appeal a claim denial, but you can also phone your insurance carrier directly to have them lead you through the process. It is possible that you will need to write a letter to your insurance provider. If so, submit your claim number as well as the number on your health insurance card.

Stay Organized

Remember that claim inaccuracies are one of the most prevalent reasons for a claim being refused. That's why you'll need to be as organized as possible with all of your claim documentation and information, down to the least detail. Keep everything together and take notes throughout each conversation with your insurance agent. Here are some things to make a note of and keep track of:

The name and the job title of each person you speak with
The date and time of each conversation
A “call reference number” for phone calls with your insurer
A document image number (if an appeal was submitted)

Staying on top of all this information will help you build your case and ensure that your appeal process can move forward without delay.

Follow Up on Your Denied Claim

In the insurance industry, the ancient adage "the squeaky wheel gets the grease" holds some validity. Set a calendar reminder to call back in a week to check on the status if an agent from your insurance company says they will resubmit your claim and it will take approximately a week to be processed. Remember that insurance companies are frequently involved in multiple lawsuits at the same time. That is why sending them a courteous reminder may increase the likelihood of your claim going through the pipeline.

Move Up the Ladder

So, what happens if you've followed all of your insurance company's procedures but your claim has been denied a second time? It's time to take things to the next level. The ACA requires states to establish an external review process for denied medical claims. Check the Centers for Medicare and Medicaid Services website to discover if your state has yet to apply the new requirements.

Speed Up the Process by Filing an External Review

If you require immediate medical attention, you may not have the time to wait the entire thirty days for a response from your insurance carrier. You can seek an accelerated appeal in this case. According to Healthcare.gov, "you'd simply need to show that the timeline for the standard appeal process would seriously jeopardize your life or ability to regain maximum function."

If this applies to you, you must file both an internal and external appeal. If your injuries or illness makes this impossible for you to do on your own, your doctor can file an external appeal on your behalf. A final judgment on an external appeal must be made as soon as possible, and no later than four business days after your appeal is received. Although a final judgment can be communicated over the phone, it must be presented in writing within 48 hours.