Tips for Appealing Insurance Denials

When you need medical care, the last thing you want to worry about is whether or not your health insurance will cover it. Your explanation of benefits (EOB) document is an important source of information about coverage. There are many reasons why medical services may be denied but you always have the right to appeal your insurer’s decision. The most important thing to remember when appealing a health insurance denial is to not give up, be persistent. Here are some tips to increase your chances to appeal a health insurance claim denial.

Investigate what happened before you start an insurance appeal

You need to know the basic rules about your health insurance plan. Firstly take the time to thoroughly understand and read through your insurance policy. What is covered under your plan? Do you need a referral to be seen by a physician or have testing completed? Verify with your insurer that your care provider is in-network and is prior authorization required?

Read thoroughly your insurance companies rejection letter sent to you. This document is important as it outlines the specific reason for the rejection and where you failed to meet the policy’s requirements or exclusions.

If it was an error on the part of your medical provider, like a misspelled name, insurance ID number, or the wrong date of service ask them to correct the problem and resubmit the request or claim. If you still aren’t sure why the claim was denied, call your plan and ask.

Common reasons for the denial

Some of the common reasons for denials include: treatment denied on the grounds of medical necessity, the drug is off-formulary, the care was provided by an out-of-network provider, the service is not a covered benefit under the plan, you have exceeded the benefit limits, or no pre-authorization was submitted.

Do not miss the appeal deadline date

To have your insurer reconsider its decision, your appeal evidence must be received within their timeframe for appeals. Each level of appeal has different submission deadlines established by the insurer, which are provided on your denial letter or explanation of benefits. If you are ever unsure of the deadlines, call your health plan directly and inquire. It is always a good idea to send your appeal documents via tracking post so that you have a documented record of submission should there be a problem in your insurance company receiving it.

Gather relevant documents and plan your response of the denied claim

As you prepare to write your appeal letter, be sure to clearly quote the service or treatment that you are seeking approval for and address the specific reason for the denial as stated by the insurer. The letter can be written by you, by a medical provider or by an advocate on your behalf. You may wish to contact the Patient Advocate Foundation (PAF) who employ case managers who assist patients through the appeal process.

In your response discuss your health problems, particularly the full history of the recent problem in question. Include any treatments or therapies you’ve tried and facts that offset the reason your claim was denied. Discuss what will happen to your condition without the treatment. Include supporting evidence, such as medical records or treatment guidelines from recognized organizations. Keep a copy of all supporting documentation submitted to the insurance company.

Seek help from your doctor

Work together with the doctor’s office staff to put together evidence to show that the care you are seeking is medically necessary. Also confirm that the prescribed care is covered by your health plan this is available online through your health plan’s member website. Relevant information about your medical history may help your request get approved.

The denial letter or 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 navigate the appeals process along with any timelines you must meet. There are appeal letter templates for healthcare providers available on various websites.

Send off paperwork before the deadline date

To have your insurer reconsider its decision, your appeal materials must be received within a timely manner or you may risk inadequate or no reimbursement. Each level of appeal has different submission deadlines established by the insurer, which are provided on your denial letter or explanation of benefits.

If you are ever unsure of the deadlines, call your health plan directly and inquire. It is always a good idea to send your appeal package via certified mail or with a tracking receipt so that you have a documented record of submission should you need to reference it at a later point. Most insurers allow two internal appeals before you can request an external review of your denial.

External appeal

If your health insurance company denies your internal appeal, you can request an external appeal to an independent review organization.

The appeals process will depend on your health insurance company, so contact them for details or look for instructions on how to file an appeal on your denial letter.

Many states offer assistance with managing medical insurance denials through its state Department of Insurance or Ombudsman programs. Free assistance from non-profit organizations may be available as well.