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What are some tips for appealing if my medical insurance claim is denied?

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  • Read the insurer’s letter for why your claim was rejected. Check your summary of benefits to see what should be covered.
  • Contact your insurer and ask about how to file an appeal. Write the name of the person you talked to, the date, and what was done or decided.
  • Call your doctor's office if your insurance says that your doctor left out information or didn't use the right code.
  • Call your employer's HR department if you have coverage from your job. Ask if they could call or write the insurer on your behalf.
  • If your insurance company refuses to pay the claim, you have a right to file an appeal and get it reviewed by an independent third party.
  • Be sure to ask if there is a deadline for filing an appeal. Let your doctor or the hospital know and ask them not to turn the case over to a collection agency until your appeal is settled.

From: How to Appeal a Rejected Claim WebMD Medical Reference

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."

Reviewed by Amita Shroff on July 16, 2018

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."

Reviewed by Amita Shroff on July 16, 2018

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THIS TOOL DOES NOT PROVIDE MEDICAL ADVICE. It is intended for general informational purposes only and does not address individual circumstances. It is not a substitute for professional medical advice, diagnosis or treatment and should not be relied on to make decisions about your health. Never ignore professional medical advice in seeking treatment because of something you have read on the WebMD Site. If you think you may have a medical emergency, immediately call your doctor or dial 911.

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