Appealing a Health Insurance Claim Denial
So you have had your claim for a medical service denied by your health insurance, but you believe it should have been paid. Your next step would be to appeal the denial with your insurance.
Appealing a denial can be a successful activity, and can often mean hundreds or thousands of dollars in your pocket that otherwise would have gone to medical bills. Not all appeals are the same, however. Some are pretty black-and-white, while others involved alot of gray. Some can be done by a savvy patient, while others will involved the help of experts, particularly nurses or doctors who were involved in your care.
Begin by understanding the denial. Was the claim denied because the medical office staff coded it incorrectly? Was it submitted with the wrong name on it? If so, you may not really need an appeal, but rather a simple re-bill. If it is a non-covered service or your insurer felt that the service was not medically necessary, then spend some time researching what exactly that means so you are armed with at least as much information as the insurance company will be.
Contact your insurer. Most insurers have a special department or number to call in cases of appeals. Call them, understand what denial was for and in what cases it would have not been denied. This can help you piece together your case for why it should be paid.
Contact the medical office. Based on what you learned in your phone call, you'll want to discuss the case with a nurse or doctor who likely deals with these types of things routinely. They may also access the medical record for you. If the medical record shows that the denial was in error (for example, it may prove that a service was medically necessary), then you'll want to include a copy with your next step.
Send a formal appeal letter to the insurer. Use a letter that very professionally states what was denied, why you believe the denial is in error, and any backup such as a copy of the policy or a medical record. Be sure to include any forms or paperwork your insurer may require. Make it clear that you expect them to be responsive, and that you will follow-up in 10-14 days.
Follow-up with a phone call every 10-14 days. Don't be shy about contacting your insurer regularly to understand where your appeal stands. These cases have a way of making it to the top of the stack if they know that you'll be hounding them. Plus, if you are on top of the case, you can serve as a go-between for things like medical record requests if they are needed. Document who you talk to and what was said.
As a last resort, involve the government. We talk in a different section about how to use an insurance commissioner when you feel like your insurer isn't playing fair. This can be cumbersome and take some time, but it is the last resort if all else has failed.