How To Appeal A Health Insurance Claim Denial – Forbes Advisor


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A health care provider typically submits a claim to your health insurance company after you receive treatment, services, medications or medical goods. The insurance company reviews the claim and decides if your health plan covers the service and how much the provider should get reimbursed. That decision influences how much you pay.

A health insurance company could deny a claim or pay much less than you expected. But there is a health insurance claim appeal process if you believe your health plan should pay for that care.

What Is a Health Insurance Claim?

A health insurance claim is a request for payment submitted by you or your health care provider to your health insurance company after you receive services, treatment, medications or medical goods that you believe are covered by your insurance plan. An accepted claim covers the bill in full or in part and reimburses the provider or patient for these costs.

Your insurer may deny the claim and refuse to pay or reimburse for the services or treatment. Kaiser Family Foundation estimates that 18% of in-network health insurance claims were denied by Affordable Care Act marketplace health insurance companies in 2020.

Why Would a Health Insurance Claim Be Denied?

A health insurance company may deny a claim for many reasons, including:

  • The treatment or service isn’t deemed medically necessary or appropriate.
  • The plan doesn’t cover the treatment, service, medication or goods.
  • The health care provider isn’t in your plan’s network.
  • Your insurer requires preauthorization or a referral from your primary care physician.
  • The treatment is considered investigational or experimental.
  • Your coverage has lapsed or you aren’t enrolled with the insurer any longer.
  • A paperwork or data entry error prevented the claim from being processed correctly.
  • The claim wasn’t filed on time.

Denied claims vs. rejected claims

A “denied” claim is actually different from a “rejected” claim. Here’s the difference:

  • A denied claim is one that the insurer finds isn’t payable. These claims may be unpayable because of vital errors or they violate the provider’s contract.
  • A rejected claim has one or more errors discovered before the claim was processed, often because there was missing or incomplete information on the claim form.

Patients or providers are typically informed about a denied claim through a mailed or emailed Explanation of Benefits or Electronic Remittance Advice. Insurers will usually explain why they denied a claim when they send the denied claim back to the submitting party. Most denied claims can be appealed.

Rejected claims must be corrected and resubmitted by you or your health care provider. If they’re eventually denied, rejected claims most likely can be appealed.

What is an expedited appeal?

You can request an expedited appeal if you believe waiting for a claim decision may put your health at risk, such as if you urgently require medication or are currently in the hospital.

An expedited appeal is allowable if the timeline for the standard appeal process would significantly endanger your life or your ability to regain maximum function. In this case, you may file an internal appeal and an external review request simultaneously.

To request an expedited appeal, explain on your appeal request form that you need a faster appeal and indicate the health reasons in your appeal request letter.

Expedited appeal decisions are typically given quickly, based on the urgency of the patient’s health condition. In most cases, this decision is given within three calendar days from the initial date the appeal was received.

Two Ways to Appeal a Health Insurance Claim Denial

There are two ways to appeal the denial of a health insurance claim: an internal review appeal and an external review appeal.

Internal review

An internal review appeal, also called a “grievance procedure,” is a request for your insurer to review and reconsider its decision to deny coverage for your claim. You have a right to file an internal appeal. By doing so, you’re asking your insurer to conduct a fair and complete review of its decision.

External review

If your insurer continues to deny coverage for a disputed claim, you have the right to pursue an external review appeal. An independent third party performs this. It’s called “external” because your insurer will no longer have the final decision over whether or not to pay for a claim.

Steps Involved With Appealing a Health Insurance Claim Denial

Step 1: Find out why the claim was denied

If you received notification from your insurer that your claim was denied, read through the correspondence carefully, including any Explanation of Benefits provided.

Your insurer is legally required to notify you in writing and explain why your claim was denied within 15 days if you’re seeking prior authorization for a treatment, within 30 days for medical services already received or within 72 hours for matters of urgent care.

If the explanation isn’t satisfactory or unclear, try contacting your insurer and learning more. Carefully document any communication with your insurance.

Step 2: Ask your doctor for help

Contact your physician’s office and ask why they believe your insurer denied your claim. It might simply be an issue like the provider office entered the wrong payment code.

Ask them to verify that the treatment or service provided was medically necessary and that the appropriate medical code was submitted to the insurer. Document anything you learn.

Gather documentation from your provider, including health records, dates, a copy of the claim form they submitted and possibly a fresh letter from your doctor requesting that the claim be accepted based on their assessment of the situation.

Step 3: Learn how and when to appeal

Review your health insurance policy, which should indicate the steps required for appealing, the deadlines to file an appeal and how and where to submit the appeal. Phone or email your insurer if you lack this paperwork.

Step 4: Write and file an internal appeal letter

Compose an appeal letter with all the pertinent facts, details and substantiation needed to defend your claim. Be as factual, concise and respectful as possible. Don’t be threatening, hostile or abusive in your words or tone.

The National Association of Insurance Commissioners offers a sample internal appeal letter.

Step 5: Check back with your health insurance company

Review your policy regarding how long you can expect to wait before your insurer reviews and issues a decision on your appeal. After that time has passed, or if in doubt, contact your insurance company to check your appeal’s status.

Step 6: File an external review appeal if necessary

If your internal review appeal has been denied and your claim remains unapproved, consider filing an external review appeal. This must be filed within four months following the date you received a final determination or notice from your insurer that your claim was denied.

Ask your insurer how to officially file an external review.

Step 7: Contact with your state

If you’ve exhausted the appeal process with the insurer, contact your state’s department of insurance, attorney general’s office or office of consumer affairs. States can help you with an external review of the claim denial.

How Long Can You Appeal a Claim Denial?

You have a maximum of six months (180 days) to file an internal appeal after learning the claim was denied.

If you file a written request for an external review, this must be done within four months following the date you received a notice or final determination from your insurer that your claim has been denied.

How Long Does a Health Insurance Company Take to Decide on a Denied Claim?

While the timeline may vary depending on your state’s laws, after filing an appeal you should expect to get a response or appeal decision within:

  • 30 days if your internal appeal is for a service you haven’t yet received
  • 60 days if you’re internal appeal is for a service you’ve already received
  • 45 days for standard external reviews
  • 72 hours for expedited external reviews
  • 7 calendar days for requested experimental or investigational treatments or services

What Is the No Surprises Act?

Congress passed the No Surprises Act that took effect in January 2022.

The legislation sought to lessen the sting of surprise medical bills for group health insurance and individual health insurance plans. The No Surprises Act bans:

  • Surprise bills for emergency services from an out-of-network provider or facility and without prior authorization
  • Out-of-network cost-sharing, including copays and coinsurance, for emergency services and some non-emergency services
  • Out-of-network and balance bills for supplemental care, including anesthesiology, by out-of-network providers who work at an in-network facility

The legislation means that you won’t be responsible for these types of common charges that lead to surprise medical bills. You still need to pay the usual in-network costs, but the health care provider and health insurance company must negotiate payment for the applicable surprise medical bill charges. They may need to go through an independent dispute resolution process if they can’t reach an agreement, but you as a member won’t be affected.

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