What to Do If You Have a Health Insurance Claim Denied

Having a health insurance claim denied can be frustrating and confusing. However, there are steps you can take to appeal the decision and potentially get the claim approved. This article outlines the basics of the appeals process and provides tips on how to effectively dispute a claim denial.

Understanding the Explanation of Benefits

The first step is to carefully review the Explanation of Benefits (EOB) statement the insurance company sent regarding the denied claim. This will give details on why the claim is considered ineligible for coverage. Make sure you understand the specific reason given, such as the service not being covered or needing prior authorization.

File an Appeal within the Time Frame

If you disagree with the reason the insurance claim was denied, you can file an appeal. There are strict time limits, typically 180 days from receiving the EOB, to start the first appeal. Note that some states may allow more time. Contact member services to learn the exact appeals window and process for disputed claims.

Levels of Appeals

Most insurance providers have a two-step appeals process – an internal first-level review and an external second-level review. If the first appeal is denied again, you can request that the claim be escalated to an external reviewer. This acts as an independent mediator between you and the insurance company.

Provide Detailed Documentation

The key to filing a successful appeal is providing all needed documentation to validate why the services should be covered. Refer to the health insurance basics outlined in the plan documents regarding which types of care are eligible per the policy. Make sure to respond to the specific reason the claim was originally denied and offer clear evidence.

Use Relevant Medical Records

Include medical records, statements from doctors, and any proof that shows why the treatment or medication was necessary, evidence-based, and the best option per clinical guidelines. Records relating directly to the date(s) of services in question are most applicable. Help demonstrate that unique patient health factors made the care essential.

Highlight Prior Authorizations

If you had received advance approval or confirmation that a planned treatment was covered, submit the documentation along with the appeal. Having a prior authorization should mean the insurance company needs to cover the claim as pre-verified. Reiterate that you made good faith efforts to follow the proper protocols.

Summarize Key Points

In your appeal letter, succinctly summarize the key arguments why the denial should be overturned. Restate the essential facts regarding your medical history, condition details, the physician’s care plan, and why this care adhered to evidenced-based best practices per experts and critical health organizations.

Be Professional

While appeals can understandably be emotional, maintain professionalism and good faith. Present a thoughtful, logical, and fact-based case explaining your side and needs. Avoid making it seem adversarial or confrontational, as reviewers may have biases against emotional appeals.

Follow Up Accordingly

Per laws, the appeals board must respond within 30 to 60 days with their decision. If the first level appeal does not result in approval, move ahead to an external review. Stay persistent in disputing if the treatment is truly medically necessary and initially authorized. Realize there are steps beyond exhausting the insurance’s appeals process, including legal options, if warranted.

In Closing

Getting an insurance claim denied places huge burdens on patients to fight wrongful rejections during vulnerable times. Learn the protocols of how to file appeals correctly, gather objective evidence of medical necessity, and perseveringly see the process through. Reach out for legal assistance from healthcare advocates or patient groups if your reasonable efforts are continually denied. With meticulous records and calm, rational disputes, many initially refuted claims can ultimately get covered.