How to Appeal a Rejected Claim

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.

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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.

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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.

WebMD Medical Reference Reviewed by Sarah Goodell on July 25, 2016

Sources

SOURCES:

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."

U.S. Department of Health and Human Services, Healthcare.gov: "Appealing Health Plan Decisions," "Consumer Assistance Program," "Has Your Health Insurer Denied Payment for a Medical Service? You Have a Right to Appeal."

U.S. Department of Labor: "What You Should Know About Filing Your Health Benefit Claim."

U.S. General Accountability Office, March 2011: "Private Health Insurance: Data on Application and Coverage Denials."

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