Appealing A Denied Medical Claim – There are probably a million things you’d rather do than call your insurance company about a bill or coverage issue. But health insurance claims are often misfiled, and it can be difficult to make sure you’re getting the coverage you expect. To help you navigate an insurance claim appeal—and not pull your hair out in the process—we spoke to Adam Fox, deputy director of the Colorado Consumer Health Initiative, and Emily Brown, patient education content and program manager at the Patient Advocate Foundation.
You will receive a formal letter in the mail stating that you received medical care or treatment that your health insurance company did not cover. It can be frustrating to say the least, especially when you believe (or have checked in advance) that your care or medications should have been covered. If your insurer doesn’t pay, “the treating health care provider will expect payment from the patient,” Brown says.
Appealing A Denied Medical Claim
In some cases, your medical bills may fall under a surprise statute. That means you won’t get surprise medical bills for out-of-network services. You can dispute these types of medical bills with your medical provider’s billing department.
Erisa Recovery Process Diagram
The process may vary depending on your insurance company. In general, the steps you can take to appeal a health insurance claim (and what to say), according to our experts:
Call your insurance company, explain why the claim was denied, and request an itemized bill from your medical provider that includes the billing codes. If you don’t get what they coded for, tell them so. Tip: You can Google medical billing codes and be sure to track your correspondence.
Script: I received a denial of [INSERT MEDICAL SERVICE OR MEDICATION] from you in a letter on [INSERT DATE]. I would like more information about why this claim was denied and my next steps.
Next, contact your doctor’s office or medical provider and ask if they plan to file an appeal on your behalf. Even if they don’t, you can still glean useful information from them, says Brown. This includes medical records and doctor’s notes detailing test results. If your insurance company says your treatment is not medically necessary, ask your provider for a letter of medical necessity.
Letter To Appeal A Medical Claim Denial
Script: My insurance claim for [INSERT MEDICAL SERVICE OR MEDICATION] I received on [INSERT DATE] was denied. I am calling to find out if your office can appeal on my behalf. If not, I would like to request my medical records for [insert date of doctor visit] visits/examinations. The insurance claim denial states that my medical treatment was not medically necessary. Can you provide a letter of medical necessity please?
Finally, look at your health insurance policy. This should tell you when and how to submit your appeal. You can ask about this when you first call your insurance company. Generally, you have up to six months to file an appeal when you receive the initial denial letter.
Once you have all of the above information, you will send a formal letter to your insurer (you will either mail this or upload it to your insurance company’s website, depending on how they require you to submit appeals). The letter should state your case for why your medical coverage should be covered, why you need the medical service or drug, and why you believe your insurance policy will cover it. “Describe your medical condition and the impact it has had on your life,” says Brown. Here’s a sample appeal letter to get you started:
[Your name or member name other than you] I am writing to appeal [name of health plan]’s decision to deny [your name or member name] coverage for [insert medical service or drug].
Appealing Denied And Reduced Claims (medical)
It is my understanding that [HEALTH PLAN NAME] is denying coverage because “[insert reason from denial letter]”. I have reviewed my policy and believe [name of medical service or drug] is covered. Name of insurance company [name of medical service or drug] I would like to appeal the denial of a claim.
[NAME OF MEDICAL PROVIDER OFFICE] team has recommended that [name of medical service or drug] is medically necessary. [Name of medical service or drug] is a covered service as stated as a benefit in your handbook: [Citation member handbook indicating treatment provided].
I was diagnosed with [NAME OF HEALTH CONDITION/Diagnosis] on [DATE]. Unfortunately, this has had a significant impact on my daily life, as evidenced by [insert symptoms]. [Name of medical service or drug] was medically necessary to treat [health condition/diagnosis] because [insert how the medical service or drug helped you]. If I do not receive [name of medical service or drug], [reason/consequence of not receiving treatment].
I have attached [document attached to list] to explain that [name of medical service or drug] is medically necessary and a covered benefit.
Consumer Reports: How To Appeal A Denied Insurance Claim
[If medical service is out of network: Establish that there are no comparable services in network.]
Please review the documentation provided and reconsider allowing coverage for [name of medical service or drug] because this treatment is necessary for my medical condition.
If you need more information, you can contact me at [phone number and email address]. Looking forward to your reply as soon as possible.
Brown says you can go a step further and provide journal articles or data that “demonstrate the benefits and success of the recommended treatment/service” in the letter. (PubMed is a good place to start). Also, provide your and your doctor’s contact information.
How To Compose An Effective Appeal Letter
Depending on your insurance company, “the standard appeals process could endanger your life or cause you serious pain or harm,” says Brown. You have 30 days for emergency medical services you haven’t received (if they deny the pre-authorization request) and 60 days for medical services you’ve already received. You can always call them and check the status in the meantime.
Script: Hi, I appealed on [INSERT DATE]. Can you please tell me if it is received and in the correct section for processing? I also want to know how long a result will take.
Every time you make a phone call, keep track of your correspondence. Once your appeal is processed, your insurer must provide a written response within the allotted time.
“A first appeal is by no means your last chance,” says Fox. You have a statutory right to a limited number of appeals. Call your health plan to find out how many you have. You can request an external appeal, says Fox. That’s where a third party will step in and review your claim (though there may be a fee).
Anatomy Of A Successful Appeal Letter: Outpatient Radiation Oncology Denial — Advent Health Partners
Script: Hello, I received a denial of my appeal submitted on [INSERT DATE]. Do I still get any appeals?
If you’ve gone through every option here and still owe medical bills, no matter how high, you can always try to lower your bill. Call the medical provider’s billing department (yes, another phone call) and ask them how you can reduce your financial liability. Remember that they get these calls all the time, and they are often willing to help. You can also ask about financial aid, medical waiver options, or payment plans that reduce the burden.
Fighting with your insurance company is frustrating. But watching the process can help you save big and avoid medical debt. If you feel lost in the process, the Health Insurance Appeal Letter Tracker can help.
This content is for informational and educational purposes only. It is not a medical opinion, medical advice, or diagnosis or treatment of any specific condition.
The Standard Long Term Disability Denial: How To Appeal
Sign up for the Daily Skimm email newsletter. Delivered to your inbox every morning, it prepares you for your day in minutes. A letter to appeal a medical claim denial will help you find out why your claim was disapproved and challenge the decision. There are many reasons why your medical claim may be denied, but if you feel that the reason given to you is insufficient, it may be a good idea to fight the decision. A letter to appeal a medical claim denial is the first step in resolving the issue.
Medical bills can be expensive, so don’t pay out-of-pocket for expenses covered by your insurance. If your medical claim is denied, a letter to appeal a medical claim denial can help you dispute the denial. You have the right to challenge decisions that you believe are incorrect or inadequately explained. Sometimes, you can fix problems with a little more information: a letter from a doctor or more information about your claim or policy. Whatever the problem, sending a letter to appeal a medical claim denial can help you get answers.
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