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Health Care Reform:

Health Insurance & Affordable Care Act

How to Appeal a Rejected Claim

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.

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.

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 60 days to ask for an external appeal. Some states and plans give you more time.
  • If you are in poor health, you may file for an outside review before the internal review is done.
  • 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.

 

 

 

WebMD Medical Reference

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