June 30, 2020
Marketplace plans (through the Affordable Care Act) denied on average 20% of in-network claims a few years back. A health plan rejecting coverage for a medical procedure can add a lot of stress to a patient with a health condition or experiencing a scare.
Have you recently received medical care, like a test or treatment, and was denied coverage by your health insurance provider?
You don’t have to accept an initial health plan decision to be the final word. You can appeal a health insurance claim denial at the point of receiving the explanation of benefits, when you get the surprise medical bill from your doctor's office, or when a prior authorization has been denied.
Insurance companies often deny health claims based on small errors, like a misspelled name or coding errors. Go over the claim in detail to make sure there are no mistakes, and ask your insurance company to do the same. They can take a second look at the claim and see if an error was made on their part in deciding to deny the claim. When your insurance company receives your request, they will review and explain their decision.
Health insurance companies can make claim denials decisions based off the following common reasons:
The healthcare provider isn’t in the health plan’s network
The healthcare provider didn’t submit the correct information to the health insurance company
A health plan needed more information to pay for the services
A health plan claims the procedure was not medically necessary, or it was the result of a pre-existing condition
A clerical error, like a misspelled name or the wrong procedure code
Make sure things like your name, address, and date of birth are all accurate. You can verify the codes for drugs (NDC) and procedures (HCPCS).
Health insurers may decline you even before a test or procedure through their prior authorization process. With this step, your doctor's office must get the health plan's go ahead first to be deemed medically necessary. For example, medical records might need to be reviewed by your health insurance company before a test like an MRI is ordered. In this case, the following steps may apply, but be sure to speak with your health insurer first to confirm.
Solving this issue can be as simple as reading through your insurance policy to see what is covered. Sort through your records and emails, or refer to the insurance company website to find a detailed copy of the plan. Match what's in your policy to any details provided to you by your health insurer as to why the health insurance claim denial occurred.
Don’t fret if you can’t find the denied item listed in your plan. 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.
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 or medical bill, 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 they don't already have access to.
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. It will save you lots of time if you have to call back and speak with someone new, because you can reference this call and the new representative can check the notes.
If you aren’t successful in reversing the denied claim with the above steps, then it’s time to learn about your insurance company's appeal process or internal review process.You’ll need to know where to send all of necessary documentation and their deadlines. If you still have the insurance company's representative on the phone, ask them for these details before hanging up. This information is often listed on the insurance company website, too.
There are plenty of sample template appeal letters available that make it easy for you to fill in and send off to your appeal request to your insurance company for internal review. Write the appeal letter, and include all required documents, like your Explanation of Benefits and a Letter of Medical Necessity. The letter of medical necessity from your healthcare provider outlines why the service or medical procedure is medically necessary.
Include details on the specific treatment or procedure that you're appealing and why you feel the claim should be paid. There are lots of tips to ensure you write a concise, effective appeal letter.
Once your health insurance provider receives the appeal and makes a decision, you'll receive written details on:
If your appeal was approved or denied
The reason for the decision
The next step in the appeals process
If you received a denial letter, try to understand why the health insurer rejected the appeal. Call them again, if insufficient information was provided in their letter. Ask for a clear explanation, and if necessary, follow the health plan's procedures for filing a second appeal. This internal review can involve a few steps, and it's recommended to go through those first before going through your state's external review process.
This whole process can take time, so be patient. It's common for this to drag out over months, or even years, because health insurance companies make this process very challenging. Coming out on the other side with the case in your favor can be very rewarding.
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.
If you need additional help, you might consider checking your state's availability of a Consumer Assistance Program to help navigate the appeals process of your health insurance plan. You might consider hiring a Healthcare Advisor (also frequently referred to as a Patient Advocate or Health Advocate) when:
You don’t have the time to do this yourself
The terms or details of the policy are hard for you to understand
You’ve exhausted all options but want to see if there’s something you’ve missed
You wish to file an independent external review as a last resort