When you are relying on your health insurance to cover costs for a procedure or important treatments, a denied claim can be stressful and inconvenient. A denied claim can be for minor or major procedures alike.
For those waiting on their insurance before receiving treatment, there could be an additional risk to their health the longer they must wait before their procedure is approved. If you think your claim merits approval, you may be able to take steps to appeal the insurer’s refusal if this occurs.
There are many reasons a claim might be denied, from missing information to a disagreement over what your insurance policy covers. If you can review the information regarding your policy, your claim and the denial, you may be able to find the information you need to dispute the insurer’s decision. Learning about the steps you can take and what is involved in this process can help you improve your chance of convincing your insurer to meet your medical needs.
Reasons for Denial
The first step to take when your claim has been denied is to determine the reason behind the denial. This is key to the actions you must take to appeal the decision. Review the denial notice from your insurer carefully and take time to research any terms you are not familiar with.
You can contact the insurance company directly to ask about the reason your claim was denied if it is not entirely apparent from their written communication. Some examples of reasons behind a claim denial may include:
- Incorrect information or an administrative error.
- Claiming a benefit not covered by your policy.
- Submitting a claim for treatment deemed not medically necessary.
- Claiming a medical issue that started before you joined the health care plan.
- Receiving treatment from an out-of-network provider.
- Receiving experimental treatment.
- Being treated in a setting not expressly covered by your policy, such as home care.
- Lack of payment on your policy.
- False information provided on your policy.
If you can prove there was a mistake made, you may be able to reverse the denial with a simple phone call to your insurance provider. For example, you could provide evidence of the necessary payments you have previously made for your policy, or you can prove your physician entered an incorrect code on your medical forms. Otherwise, you must take additional steps to complete the process of receiving approval for your medical procedure or recommended treatment plan.
Review Your Policy
Once you know the reason your claim was denied, you must review your policy in detail to gain a complete understanding of what is covered and what may not be covered in your plan. If the cause for denial is not reflected in the policy, you can inform the insurer. The policy may help you determine whether any type of error has been made regarding the information provided by your doctor.
Records
Accurate and detailed records are important throughout the appeals process. Any time you contact your insurer, you must make a note of the person you speak to and what is said during your conversation. You may be able to speak with the same member of staff throughout the process.
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You must collect records of the claim, the denial and any other paperwork involved. These records could highlight some simple administrative error, such as an incorrect medical code. Otherwise, you can at least be sure you are fully prepared for any conversation with your insurance company regarding potential issues.
Involve Your Doctor
Depending on the reason for your claim’s denial, you may need to involve your medical provider. If your claim was denied because a treatment was deemed unnecessary, your medical provider could help you prove it was needed. There may be a precedent set for a specific treatment being covered by your plan, for which your medical provider has records reflecting the request for this treatment. If you are claiming for an unapproved treatment plan, your doctor could provide you with the approval you need.
Review the Appeals Process
When you have the information you need, you can begin the appeals process. Make sure you are familiar with the steps your insurer requires for this process as this can help you successfully complete the process the first time around. If you file an appeal, the insurance providers are obliged to provide information regarding their appeals process. You may wish to research this information beforehand as well, to ensure you have all the documentation you might require.
Internal Appeal
This is the first step in the appeals process. You may receive forms from your insurer to fill out for the initial appeal. Alternatively, you can write a letter of appeal detailing your case and claim if you have not received these documents from your provider. The letter of appeal must be sent within 180 days of the claim being denied.
If you need assistance, you can go to your state’s Consumer Assistance Program. Your doctor may be able to file the appeal for you provided you made the initial request yourself.
If you are in an urgent situation, you typically receive the denial within 72 hours of your claim. After this has happened, you have the option of sending an expedited request for an appeal.
The appeal must contain the evidence required to argue your claim is valid, such as medical or payment records. You can send in a letter from your doctor supporting your claim as well if you do not have the appropriate records or if you simply would like to strengthen your case.
The appeals process must be completed within 30 days if you are claiming for a procedure, treatment or service you have not received yet. If claiming for a service you have received already, the process must be completed within 60 days.
External Review
If your internal appeal was denied, you can file a request for an external review. This must be filed within 60 days of the decision. The process typically takes around 60 days to be completed. The rules regarding external reviews may vary from state to state, and it is important to research your state’s laws to gain a better understanding of what to expect in your specific case.
The review is conducted by a third party and their ruling must be followed by the insurer. There are only three types of appeals eligible for external review:
- A disagreement regarding a medical judgement.
- A treatment that has been determined to be “investigational” or “experimental”.
- A determination you provided false information when taking out your policy.
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