How to appeal a health insurance claim denial — and win!
Fighting a health insurance company over a claim denial might sound like a David vs. Goliath struggle, but the battle is worth waging if you’ve got a legitimate case — and winning is easier than you might think.
Health insurance companies in most cases aren’t out to cheat you. Many wrongful claim denials stem from coding errors, missing information, oversights or misunderstandings.
Here are six steps for winning an appeal:
1. Find out why the health insurance claim was denied
The insurance company should send you an explanation of benefits form that states how much the insurer paid or why it denied the claim.
Call the insurer if you don’t understand the explanation, says Katalin Goencz, director of MedBillsAssist, a claims assistance company in Stamford, Conn.
If it’s a simple error, the insurer might offer to straighten it out. But double check to make sure your insurer follows through, Goencz says.
“Get the name of the person you spoke to, the date, the reference number for the phone call, and put it on your calendar to check back with the company in 30 days,” she says.
2. Read your health insurance policy
Understand exactly what is covered under your policy and how co-pays are handled. Health insurance plans differ. For example, find out if you have an HMO or a PPO. Usually the health insurer includes a summary of benefits online, but you should read the policy itself, says Rebecca Stephenson, president and CEO of VersaClaim, a claims assistance and patient advocacy business in Austin, Texas.
“This is not a document you store in the attic with your old tax records,” she says. “It needs to be close at hand.”
Can’t find it? Ask the employee benefits department or your broker for a copy.
3. Learn the deadlines for appealing your health insurance claim denial
Read your health plan and learn the rules for filing an appeal.
“You want to know how under the gun you are,” Stephenson says.
If it’s a complex case and you’re concerned about meeting the deadline, send a letter stating you’re appealing the denial and will send further information later, Stephenson says.
4. Make your case
Gather documentation to back up your argument. Sometimes the problem stems from something as simple as a billing mistake by a doctor’s office.
Stephenson tells of one client whose health insurance company denied a claim for surgery because her deviated septum was named as the diagnosis. The insurer did not cover surgeries for a deviated septum.
But she was also diagnosed with acute purulent sinusitis — the real reason for the surgery, which was never communicated to the insurance company.
Stephenson had the client submit copies of her medical reports, X-rays and a letter from the physician confirming the sinusitis diagnosis. The patient won.
5. Write a concise appeal letter
When you write an appeal letter, be sure to include your address, name, insurance identification number, date of birth for the person whose claim was denied, date the services were provided and the health insurance claim number, Goencz says.
“The first sentence should state that you are appealing the claim denial, and the body of the letter should explain why the medical bills should be paid,” Goencz says. “Put in a closing sentence demanding payment, and include supporting documentation.”
Save emotional rants for understanding friends, and stick to the facts.
“[Insurers] don’t want to know about your grief and how sick you’ve been,” Stephenson says.
Send by certified mail to get notification that the packet was received, she adds.
6. If you lose, try again
“If you lost your first appeal, you’ve got to step back and look at why the health insurer is saying no,” Stephenson says. “What other information do you need to give them to state your case?”
Then, follow the health plan’s procedures for filing a second appeal.
If you exhaust the appeal process and are still unsatisfied, you can take the case to the state department of insurance, unless your coverage is through an employer that is self-insured. In that case, your next stop is the U.S. Department of Labor, although both Goencz and Stephenson say getting federal officials to act is a long shot.
Overwhelmed? Hire a professional patient advocate or claims assistant. You can get names of claims assistance professionals in your area through the Alliance of Claims Assistance Professionals.
Tips for Appealing a Denied Health Insurance Claim
When you need medical care, the last thing you want is to worry about whether your health insurance will cover it. Unfortunately, your medical claim may be denied for many reasons. Luckily you have some recourse to get the insurance company to reverse its decision.
Your right to appeal a denied claim was expanded under the Affordable Care Act. Now your insurance company is required to tell you why your claim was denied, and you have up to six months to appeal.
You can maximize the chances that your appeal will be successful by following these tips.
1. Understand why your claim was denied
Before you can fight a denied claim, you need to understand why it was denied. Your explanation of benefits (EOB), a standard form sent by the insurance company whenever your claim is approved or denied, uses codes to explain how the company arrived at its decision. Most EOBs will also provide a key to the codes, so you can find out what they mean. If you still aren’t sure why the claim was denied, call the company and ask. You have a right to this information, and the insurer has a responsibility to explain it in terms you can understand.
2. Eliminate easy problems first
Sometimes your claim was denied only because of a data-entry error like a misspelled name, insurance ID number, or the wrong date of service. Read through all the documentation from your insurance company carefully and look for errors. If you find one, ask the insurance company to correct it before you proceed. If it was an error on the part of your medical provider, ask her to correct the problem and resubmit the claim.
3. Gather your evidence
Make sure you have all the evidence to show that the services you want covered are medically necessary. Referrals, prescriptions from your doctor and any relevant information about your medical history may help your claim get approved the second time around. You or your doctor will also want to reference your health plan’s medical policy bulletin or guideline for the treatment you received. These are often available online through your health plan’s website.
4. Submit the right paperwork
You may need to write a letter to your insurance company. If you do, make sure to include your claim number and the number on your health insurance card. But your claim may be processed faster if you use the insurance company’s standard appeals form. The explanation of benefits you received should tell you how to appeal the decision, or you can call your insurance company directly and find out how to appeal.
5. Stay organized
The insurance company has its own internal system for tracking your medical claim and any subsequent appeals. You have to be just as organized to make sure you’re following up on any detail that may make the difference. Keep all your paperwork in one place and take careful notes during every phone call with the insurance company. Ask for the name and the job title of the person you’re speaking to and write down the date of the conversation and any next steps. You should also ask for what’s termed a “call reference number,” and if an appeal was submitted, get the “document image number.” This information will help you build your case and ensure that the next customer service agent you speak to can quickly access all the necessary files to help you move the appeal process forward.
6. Pay attention to the timeline
It’s easy to call the insurance company once and then forget about it, but you have to follow up. Set up a system to remind yourself to follow through. If a customer service agent tells you he is going to resubmit your claim and it will take about a week to be processed, make a note in your calendar to call back in a week to check on the status. The company is more likely to move your claim through the pipeline if you apply a little gentle pressure.
7. Don’t shoot the messenger
Having a claim denied is scary. If you’re waiting for pre-approval before you can have tests or a necessary procedure, it can be even worse. But don’t forget that the person on the other end of the phone is probably not the person responsible for denying your claim. She might be a valuable ally, so treat her with courtesy and respect. If you find yourself getting upset, explain that you’re very concerned about your case but you know it’s not her fault.
8. Take it to the next level
Until now, you’ve been appealing the decision directly with your insurance company. But if your claim is denied a second time, you may have one more chance to change their minds. The Affordable care Act requires that states set up an external review process for denied medical claims. Check the Centers for Medicare and Medicaid Services site to see whether your state has implemented the new guidelines yet.
How to Appeal a Rejected Claim
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You recently had a medical procedure, but now your insurance won’t pay for it. If that’s what you are facing, you’re likely frustrated and upset. But don’t panic. You may be able to get your plan to reverse its decision.
Step 1: Review Your Policy and Paperwork
Look over the summary of benefits in your insurance documents. The paperwork must spell out what’s covered. It also has to list the limitations or exclusions, which are things your insurance won’t cover.
Then read over the letter or form your insurance plan sent you when it denied your claim. It should tell you why the claim was denied. The letter should tell you how to appeal your health plan’s decision, and where you can get help starting the process.
Step 2: Know Who to Call for Answers
Some denials are easier to fix than others. It’s important to know who to ask for help.
Call your insurance company if you don’t know why your claim was denied or if you have other questions about it. Be sure to ask if the claim was denied because of a billing error or missing information.
If you think you may want to appeal the decision, ask the representative to go over the process with you or to send you a description of how to appeal.
Keep records. Write the name of the person you talked to, the date, and what was done or decided. Do this for every phone call.
Call your doctor’s office if your insurance says that your doctor left out information or didn’t use the right code. Ask your doctor’s staff to fix the error and send the paperwork to your insurance again.
Call your employer’s HR department if you have coverage from your job. Speak to the health benefits manager. He or she could help. For instance, ask if your employer could send a letter — or place a call — explaining why your claim is valid. That could convince the insurance company to reverse its decision and pay the claim.
Step 3: Learn About the Appeal Process
If your insurance company refuses to pay the claim, you have a right to file an appeal. The law allows you to have an appeal with your insurer as well as an external review from an independent third party.
- You must follow your plan’s appeal process.
- Check your plan’s web site or call customer service. You’ll need detailed instructions on how to file an appeal and how to complete specific forms.
- Be sure to ask if there is a deadline for filing an appeal.
If you’re filing an appeal, let your doctor or the hospital know. Ask that they hold off on sending you bills until you hear back from your insurance company. Also, make sure that they won’t turn your account over to a collections agency.
Step 4: File Your Complaint
Call your doctor’s office if your claim was denied for treatment you’ve already had or treatment that your doctor says you need. Ask the doctor’s office to send a letter to your insurance company that explains why you need or needed the treatment. Make sure it goes to the address listed in your plan’s appeals process. Ask for a copy of the letter to keep in your files.
The first step in an appeal is called an internal review. It begins when you file a complaint to appeal a denied claim. Your claim will get a second look by insurance company employees who weren’t involved in the original decision. If you are in an urgent medical situation, you can request an expedited appeal which requires the insurance company to make a decision within 72 hours.
After the internal review, your insurance company will call or send you a letter about its decision. If the insurance company overturns the initial decision, your care will be covered. If it upholds the decision, you still have other options.
If you’re not happy with the outcome, you can take it to the next level. Ask for an external appeal. People who don’t work for your insurance company — called an independent third party — will do their own review.
- Usually, you will have four months from the denial of your internal appeal to ask for an external appeal. Some states and plans may have different deadlines.
- If you are in poor health, you may file for an outside review before the internal review is done. You may also request an expedited review if a decision is needed quickly for health reasons. In an expedited review, the external review organization must make a decision on your appeal within 72 hours.
- You can send in additional information to support your claim.
- Some plans require more than one internal review before you can submit a request for an external review.
You can get help filing an appeal. Your state may have a Consumer Assistance Program that can answer questions and guide you through the process. Find out at healthcare.gov.
If your insurance comes from your job or your spouse’s job, contact the human resources or benefits department for information about how best to proceed.
Step 5: Keep a Problem From Happening Again
You are less likely to have a claim denied if you follow these steps before getting medical services:
- Know exactly what’s covered by your plan. Check your summary of benefits or call your insurer before you get treatment.
- Follow the rules of your health plan. For some types of care, your insurance may require pre-authorization. Check this before getting treatment.
- Find out about any limits on your benefits. For instance, does your plan say you can have only so many home health visits in a year? Read your insurance documents carefully.
- Learn if your provider is in your plan’s network. Depending on the type of plan you have, your insurer may not pay anything for care received by providers that do not participate with your health plan.
Fair Health, Inc.: “Appealing a Reimbursement Decision.”
Families USA: “Your Right to Appeal: Ensuring the Right to Appeal Health Plan Decisions.”
National Consumers League: “Five Steps for Appealing a Health Claim Your Insurance Won’t Cover.”
Patient Advocate Foundation: “Your Guide to the Appeals Process.”
What to Do If Your Homeowners Insurance Claim Is Denied
Imagine that you spent several hundred dollars or more on homeowners insurance coverage, just so that you could have a little peace of mind if something went wrong. Now imagine that your insurance company denied your claim after your home was damaged or ruined beyond repair.
Denied claims make your life much more complicated, especially when you don’t have the cash to pay for the repairs on your own. But don’t start thinking of ways you can live with those burst pipes or that tree through your roof just yet. Take a deep breath and read on. There may still be hope.
What You Can Do
Remember, your insurance company is a business. They don’t like to give away money if they don’t have to. They make a habit of denying claims to their loyal customers because they don’t want to be the ones to foot the bill.
If you are the victim of a traumatic incident which has caused extensive damage to your property, you deserve the chance to rebuild your life. Here are some tips that may change the outcome.
1. Review Your Claim
Insurance claims are full of jargon and can be hard to follow. If you can get past the technical and awkward wording, you will find out why a claim was denied. At least, those details should be listed in your policy.
If they aren’t, you shouldn’t simply throw the claim away and vent about paying for the damages yourself. Pick up the phone and call your insurer. They are legally obligated to explain why it was denied.
2. Know Your Policy
Insurers are very thorough when they write their homeowners insurance policies. They want to make sure they have a valid contract that spells out your rights and when you will be given or denied coverage. If your claim was denied, always go back and review your policy. If it was damaged in a fire or other accident to your home, you can get another copy from your insurance company. Once you have the policy in front of you, focus on the following:
- Review Your Rights. Make sure you review your rights and know if your claim was denied with or without cause. It is possible your claim was simply denied because of a filing error on the part of your insurance company. It is also possible that someone new to the office was responsible for denying the claim without fully understanding the policy.
- Understand Policy Maximums. Your insurer may have mistakenly limited your coverage to an amount lower than what they were legally required to pay. Again, this is probably due to a filing error or confusion with another policy rather than fraud. Either way, make sure you catch the discrepancy.
Understanding your policy in detail is essential. If you catch a mistake on the part of an insurer, you have a good chance of appealing their decision or taking them to court. You will only have that chance if you take the time to look.
3. Gather Details
If there is a discrepancy with your claim and you feel it was unfairly denied, you may have to prove your case. Before you can file an appeal, gather evidence to support it. The process will vary depending on the circumstances, but you may have to do one or more of the following:
- Know the facts regarding the incident itself (dates, extent of damage, parties involved, steps you took to prevent the incident and any extenuating circumstances).
- Request an independent appraisal if their is a disagreement over the value of your home.
- Take pictures of damages.
- Show records of any purchases you made to protect your home (such as home fire safety alarms and home security systems).
- Find witnesses who may speak on your behalf.
- Document all conversations you have had with your insurance company.
- Show all evidence that you are a responsible homeowner, and are not liable for any incidents if the claim was denied due to negligence on your part.
The last thing you want to do before you make an appeal is go in unprepared. Remember, tens of thousands of dollars could be at stake.
4. File an Appeal
If you believe your claim was denied without reason and should be covered under your existing policy, you can try to file an appeal with your insurance company directly. They will provide details on how to make an appeal if you wish to do so. An appeal isn’t a guarantee that the decision will be changed, but it is worth a shot.
Make sure you document all evidence to support your claim. Here are a couple of examples of things you’ll need.
- Photo and Written Documentation of Damages. A picture can speak a thousand words and a written document is very helpful as well. Take plenty of photos of the damage, from multiple angles, and write a clear description of what happened.
- Any Documentation of Inspections and Maintenance. One of the most common reasons claims are denied is due to negligence or recklessness on the part of homeowners. Do everything you can to prove you are not at fault for any damages in your home. Show that everything was up to code and that you were a safe and responsible homeowner. Whatever their reasoning for denying your claim, make sure that you can support your own position.
If your appeal is still denied, the only option you have left is to take the insurer to court or a private arbitrator. This is something you should seriously consider if you just lost a one hundred thousand dollar home. Make sure you have records of all transactions with your insurance company to back yourself up when you go into the courtroom. Get a good lawyer to support you. They may be expensive, but their fees won’t even compare to the cost of losing your claim.
Insurance companies deny claims all the time. Sometimes they have just cause to do so, but they can make mistakes as well. Whether they make a simple filing error or misread the terms of your policy, you shouldn’t have to be the one to suffer. You deserve restitution if your home has been damaged or destroyed, so make sure you understand your policy and your options before you throw in the towel.
Have you filed a homeowner’s claim and been denied? What steps did you take in response? Share your experiences in the comments below.