Insurance Denials: Six Steps to Appealing an Insurance Denial

Wednesday, June 11, 2014, 1:00 AM | Leave Comment

Medical expenses are more than most people can pay. We pay into insurance plans, but what if the insurance company denies your claim? You play your monthly premiums, thinking you will be taken care of. Luckily, you can appeal an insurance denial. It isn’t easy or fun, but it can save you a lot of money.

If you have made a medical claim to your insurance company for payment of care or to repay you for care you have already received and your claim is denied, you have the right to appeal the decision.

All health insurers, including Medicare, are required, by law, to have a process for appeals. The patient may file an appeal if the insurance company does one of the following:

  • Denies payment on a procedure you believe is covered.
  • Denies payment for treatment that you have already received.
  • Changes the amount you are requested to pay for prescriptions.
  • Stops coverage that was previously given.

An internal appeal in which you ask the insurance company to give a full and fair review of its decision. If your case is urgent, they must expedite the review. This is the first step.

An external review in which you may make your case to an independent, third party for review. The insurance company does not make the final decision.

Six Steps to Appealing an Insurance Denial

Here are six steps you can follow to appeal the denial.

  1. Find the reason the claim was denied. According to law, the insurers must tell you why they denied the claim. They must also tell you how to appeal the denial as well as how to request an external review.

  2. Check your policy to make sure your procedure or prescription is covered.

  3. Find your insurer’s appeals process. Each insurance company may have a different process.

  4. The formal appeal must be submitted within the timeframe stipulated in the appeals process of your insurance company.

  5. Save copies of all communications involved in the appeal process including your personal notes about the people you have spoken to and the supporting information from doctors, hospitals or other healthcare givers. You may include letters from your doctor that state the medical necessity of the prescription drugs or other service you need.

  6. By law, the insurer must respond to the receipt of an appeal within 72 hours for urgent care, within 30 days for other services and within 60 days for services already received.

If your insurance company continues to deny the claim, you should request an external appeal. The insurance company must comply with your request according to state law. The laws vary by state.

The decision made by the third party will be binding for both you and the insurance company. If you insurance company is an employer self-funded plan, there are more appeal steps you can take.

Author BIO

Kara Masterson is a freelance writer from West Jordan, Utah. She graduated from the University of Utah and enjoys writing about personal finance and spending time with her dog, Max Information credited to SBMB Law Markham, Lawyer

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