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Health Care Reform:

Health Insurance & Affordable Care Act

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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