Caribou: 4 Steps to Appeal a Denied Insurance Claim

June 30, 2020



June 30, 2020

On top of the already looming stress from cancer, a claim denied by insurance can make things seem much worse. 

There isn’t a set list of health insurance claim denial reasons, but you don’t have to accept an initial decision from insurance to be the final word. It is easy to appeal your denied claim by following these five steps. 

Step 1: Go over your denied insurance claim

Insurance companies are notorious for denying claims based on small errors, like a misspelled name or the wrong procedure code. Go over the claim in detail to make sure there are no mistakes. 

Make sure things like your name, address, and date of birth are all accurate. You can use this tool to verify the codes for drugs (NDC) and common procedures (HCPCS).

Step 2: Review your cancer insurance policy

Solving this issue can be as simple as reading through your insurance policy to see what is covered. Sort through your records or emails, or refer to the insurance company website to find a detailed copy of the plan. 

Don’t fret if you can’t find the denied item listed in your plan, as you can still move onto the next step. But while you go through this step, be sure to know how to find your insurance policy number, as you’ll need it for the next step. 

Step 3: It’s time to call your insurance company

Have your policy number ready. When you have a representative on the line, clearly state that the denied insurance claim should be approved. Speak confidently and refer to the appropriate section of your policy, if you can. Sometimes, you simply need to give more detailed medical information to support your claim, so add any new and important information that you didn’t include in your initial claim.

Each time you speak to someone from your insurance company, be sure to write down the person’s name and job title, the time and date of the call, and the call reference number (ask them for this before hanging up). This will save you lots of time if you have to call back and speak with someone new.

Step 4: Appealing the denied insurance claim

If you aren’t successful in reversing a denied claim with the above steps, then it’s time to learn about your insurance appeal process. You’ll need to know where to send it, the necessary documentation, and the relevant deadlines.

If you still have a representative on the phone from the insurance company, ask them for these details before hanging up. This information is often listed on the insurance company website, too.

Write your appeal letter using a template that is easy for you to fill in and send off to your insurance company. There are also required documents, like an Explanation of Benefits and a Letter of Medical Necessity, that will need to be included to file an effective appeal letter. 

When should you get help with a denied health insurance claim?

The above steps are easy to follow on your own when faced with a denied insurance claim. Some will be more successful than others in going through the steps, but know that there is professional help to work with you. 

You might consider hiring a Healthcare Advisor (also frequently referred to as a ‘Patient Advocate’):

  • When you don’t have the time to do this yourself

  • If the terms or details of the policy are hard for you to understand

  • If you’ve exhausted all options but want to see if there’s something you’ve missed

Contact Caribou today to have a Healthcare Advisor work with you through a claim.