Insurance Appeals

When you need medical care, the last thing you want is to worry about whether your health insurance will cover it. Unfortunately, your medical claim may be denied for many reasons. Luckily you have some recourse to get the insurance company to reverse its decision.

Your right to appeal a denied claim was expanded under the Affordable Care Act. Now your insurance company is required to tell you why your claim was denied, and you have up to six months to appeal.

You can maximize the chances that your appeal will be successful by following these tips.

1. Understand why your claim was denied
Before you can fight a denied claim, you need to understand why it was denied. Your explanation of benefits (EOB), a standard form sent by the insurance company whenever your claim is approved or denied, uses codes to explain how the company arrived at its decision. Most EOBs will also provide a key to the codes, so you can find out what they mean. If you still aren’t sure why the claim was denied, call the company and ask. You have a right to this information, and the insurer has a responsibility to explain it in terms you can understand. There are generally one of several reasons why:

  • You have noncovered charges - It’s possible that the procedure you had wasn’t covered by your health insurance policy, even if it seems to you like it should have been. Look again at the terms of your policy, because some plans don’t cover certain categories of care, such as infertility treatments or dental surgery. If you think you’ll need care in the future that’s excluded from your current policy, you may want to shop for a new policy.

  • A referral or pre-authorization was required - Procedures like CT scans or MRIs usually require pre-authorization, which your doctor should request on your behalf. Sometimes the procedure provider will turn you away if you don’t have pre-authorization; in other cases, your claim might be denied afterward. If your claim was denied but your doctor ordered the tests, ask your doctor to contact the insurance company on your behalf.

  • You used an out-of-network provider - If your insurance is a health maintenance organization or an exclusive provider organization, your claim may have been denied for going outside of the plan’s provider network for care. Going out of an HMO or EPO network means you’re seeing a provider who hasn’t agreed to your insurance company’s terms of payment. If you received elective or nonemergency care and do not have any out-of-network benefits, your health plan may deny the claim (making payment your responsibility) or require you to pay a bigger share of the cost.

  • There are minor transcription errors - Is your name misspelled? Does your birth date say you were born in 1978 instead of 1987? If you can’t figure out why your claim wasn’t paid, check for typos. It wouldn’t be the first time a claim was denied because of minor data entry errors. In that case, call a customer service representative to help you fix the data problem.

  • The bill went to the wrong insurance company - This is really basic: Did your doctor’s office bill the right company? Are you sure you have an active policy? If you’re seeing a provider you haven’t seen in a while, it may have outdated insurance information on file for you. Having two policies can also cause some claims to be denied. For example, if you have coverage through your own employer and your spouse’s employer, it can cause problems with billing. Double-check that your provider has up-to-date information in a timely manner, because if the claim is filed too late with the correct insurer, it could be denied.

2. Eliminate easy problems first
Sometimes your claim was denied only because of a data-entry error like a misspelled name, insurance ID number, or the wrong date of service. Read through all the documentation from your insurance company carefully and look for errors. If you find one, ask the insurance company to correct it before you proceed. If it was an error on the part of your medical provider, ask her to correct the problem and resubmit the claim.

3. Gather your evidence
Make sure you have all the evidence to show that the services you want covered are medically necessary. Referrals, prescriptions from your doctor and any relevant information about your medical history may help your claim get approved the second time around. You or your doctor will also want to reference your health plan’s medical policy bulletin or guideline for the treatment you received. These are often available online through your health plan’s website.

4. Submit the right paperwork
You may need to write a letter to your insurance company. If you do, make sure to include your claim number and the number on your health insurance card. But your claim may be processed faster if you use the insurance company’s standard appeals form. The explanation of benefits you received should tell you how to appeal the decision, or you can call your insurance company directly and find out how to appeal.

5. Stay organized
The insurance company has its own internal system for tracking your medical claim and any subsequent appeals. You have to be just as organized to make sure you’re following up on any detail that may make the difference. Keep all your paperwork in one place and take careful notes during every phone call with the insurance company. Ask for the name and the job title of the person you’re speaking to and write down the date of the conversation and any next steps. You should also ask for what’s termed a “call reference number,” and if an appeal was submitted, get the “document image number.” This information will help you build your case and ensure that the next customer service agent you speak to can quickly access all the necessary files to help you move the appeal process forward.

6. Pay attention to the timeline
It’s easy to call the insurance company once and then forget about it, but you have to follow up. Set up a system to remind yourself to follow through. If a customer service agent tells you he is going to resubmit your claim and it will take about a week to be processed, make a note in your calendar to call back in a week to check on the status. The company is more likely to move your claim through the pipeline if you apply a little gentle pressure.

7. Don’t shoot the messenger
Having a claim denied is scary. If you’re waiting for pre-approval before you can have tests or a necessary procedure, it can be even worse. But don’t forget that the person on the other end of the phone is probably not the person responsible for denying your claim. She might be a valuable ally, so treat her with courtesy and respect. If you find yourself getting upset, explain that you’re very concerned about your case but you know it’s not her fault.

8. Take it to the next level
Until now, you’ve been appealing the decision directly with your insurance company. But if your claim is denied a second time, you may have one more chance to change their minds. The Affordable care Act requires that states set up an external review process for denied medical claims. Check the Centers for Medicare and Medicaid Services site to see whether your state has implemented the new guidelines yet.

9. Speed things up
If you need medical care urgently, you may not be able to wait for the company’s internal appeals process to run its course. “You can file an expedited appeal if the timeline for the standard appeal process would seriously jeopardize your life or your ability to regain maximum function,” says In such cases, file internal and external appeals simultaneously. If you’re too sick to take care of this on your own, your doctor can file an external appeal on your behalf.