How to Get a Health Insurance Claim Paid and Appeal a Denial
You’re certain you did everything right when you put together that health insurance claim. You filled out every field on the claim form, provided an itemized bill for every single service, and even wrote a cover letter summarizing your care.
But apparently, that wasn’t enough for your insurance company. In a businesslike — OK, borderline rude — letter, they denied your claim. Now you’re left with a couple thousand dollars in medical debt and no clear plan to pay it off.
Or maybe you’re not. Your denial letter isn’t the end of the story — it doesn’t have to be, anyway. If you’re persistent and file a proper appeal, you could get that claim paid after all, at least in part.
How to File an Appeal for a Health Insurance Claim Denial
You always have the right to appeal a denied health insurance claim. It takes work, but that’s well worth it if it means erasing a sizable bill.
Follow these steps to file an internal appeal with your insurance company. With any luck, that’ll be the end of it, and you won’t have to file an external appeal, but if you do, there are instructions for that too.
1. Review the Insurance Company’s Denial Letter
Health insurance companies don’t deny claims with no explanation. They send a letter explaining the reason for the denial.
The most common reasons insurance companies deny claims include:
- The provider made a billing or coding error.
- The insurance company made a clerical error.
- You received service from an out-of-network provider.
- The initial claim was incomplete due to missing or incorrect paperwork.
- The claim didn’t include enough information for the insurer to make a decision.
- The insurer decided the service or procedure wasn’t medically necessary.
- Your health insurance plan didn’t cover the service or procedure.
- The insurer denied the claim during the pre-authorization process, also known as prior authorization, which health insurers use to limit payment for unnecessary medical care, or you received care that requires pre-authorization without it.
Your first step is to review this letter. Even if it doesn’t have much detail, the reason for the denied claim and any explanation for it could offer a road map for your appeal.
If the letter doesn’t have much useful information, call the insurance company’s claims processing department. The number should be on the denial letter.
Ask them for a full explanation of the denial. Ideally, get this verbally from the customer service representative and in writing so you have an official record from the company. Request a written copy of the explanation in any case.
If the company denied the claim for a very simple reason, like a transposed number in a billing code, the claims representative might offer to fix it on the spot. In that case, you can pause your appeal until you receive mailed confirmation the insurance company accepted your claim. But don’t count on being so lucky.
2. Gather Documentation
Next, gather documentation to support your claim. The documents you need depend on why the insurance policy denied your claim.
Contact the hospital or doctor’s office and ask them for a detailed, itemized bill for the services you received. This document is more detailed than the explanation of benefits you received from your insurance company.
If the insurer denied the claim due to a billing error or inaccurate paperwork, ask them to double-check that they’ve included all relevant information and the correct service codes. For faster service, have them send everything to you through their secure electronic messaging system, if possible.
If the insurer denied the claim because it decided the procedure or service wasn’t medically necessary, ask your provider’s office for a letter of medical necessity. This letter should explain why you needed the procedure or service and should make clear that a licensed medical provider recommended it.
Additional information that could support a medical necessity claim includes:
- A note from your employer saying your condition prevented you from fulfilling your duties
- Peer-reviewed studies showing the benefits of a newer or alternative treatment not covered by your insurance company
- A second opinion from another licensed medical provider confirming your treatment plan
- Medical records that provide more information about your symptoms and how your condition has changed over time
3. Keep Detailed Notes
Keep detailed notes of every interaction with your insurance company, health care provider, and anyone else involved in your appeal. For each interaction, record:
- The name and title of the person you speak with
- Their contact information, including phone number and email address
- What you discuss in as much detail as possible
- The outcome of the conversation, including next steps for you and the person you speak with (or their employer)
Save these notes in a folder on your computer or phone. Transcribe handwritten notes soon after you take them so you don’t misplace them.
4. Write an Appeal Letter
Once you’ve gathered all the necessary documents, write a concise, factual appeal letter.
Above the body of the letter, include:
- The initial claim number
- The insurance identification number
- The date or dates of medical care
- The insured’s name
- The insured’s mailing address
- The insured’s birthdate
In the first paragraph of the letter, say you want to appeal the denied claim and clearly state why.
Use the rest of the letter to explain why the reasons for your appeal are valid. If the insurer decided your treatment wasn’t medically necessary, list the reasons this isn’t the case. Always point back to supporting evidence, such as a letter of medical necessity or copies of relevant plan documents. Include copies of these supporting documents with your appeal.
Avoid emotional language or unnecessary information. If it’s relevant to your claim, you can discuss issues with the insurance company’s initial review process, but avoid personal attacks or rants. End the letter with a clear demand that the insurer accept your claim and pay your medical bills.
Contact your insurer within 10 days of submitting the appeal to confirm they received everything. Then contact your health care provider and let them know you plan to wait for the insurance company’s decision before paying any bills.
5. Wait for the Insurance Company’s Decision
Don’t expect your insurance company to process your appeal right away.
Even if it’s a straightforward fix, they must review your documents and letter and determine whether to reverse the denial. That can take up to 60 days, though many appeals resolve within a few business days.
Look out for a letter from your insurance company explaining its decision. Feel free to call if you don’t see anything within a few weeks. But it’s likely the appeal is still in the internal review stage and the powers that be haven’t made a decision yet.
What to Do if Your Health Insurance Appeal Is Denied
If the internal appeal process ends with another denial, move to the next step. That’s an external appeal, also known as an external review.
External appeals usually involve an independent third party that helps consumers with insurance claims and appeals. Depending on your situation, you can:
- Hire an independent claims adjuster or health insurance attorney through the Alliance of Claims Assistance Professionals.
- File a complaint with your state department of insurance or insurance commissioner.
- Enroll in a nonprofit consumer assistance program for insurance customers — check your explanation of benefits for programs serving your area.
- If you have health insurance through a self-insured employer, file a complaint with the U.S. Department of Labor.
If you hire an independent third party to help with your claim, you may need to pay them a portion of any reimbursement they help you secure. If you file a complaint directly with your state insurance department or U.S. Department of Labor, you won’t have to pay anything out of pocket. However, professional claims adjusters and attorneys may increase the likelihood of success.
Medical bills are expensive. Really expensive. Even partial reimbursement following a successful appeal can put hundreds or thousands of dollars back in your pocket.
Crafting a health insurance appeal takes time and persistence, but it’s not overly complicated. With the correct supporting documents and a strong appeal letter, your insurer might rethink.
That said, it’s OK to take your denied claim as a sign to change health insurance coverage. Visit the Affordable Care Act marketplace to see if you’re eligible for an individual health plan. Or see about your options for coverage through your employer.