If that's what you are facing, you're likely frustrated and upset. You may be able to get your plan to reverse its decision. Look over the summary of benefits in your insurance documents. The paperwork must spell out what's covered. It also has to list the limitations or exclusions, which are things your insurance won't cover. Then read over the letter or form your insurance plan sent you when it denied your claim. It should tell you why the claim was denied.
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The letter should tell you how to appeal your health plan's decision, and where you can get help starting the process. Some denials are easier to fix than others. It's important to know who to ask for help.Ĭall your insurance company if you don’t know why your claim was denied or if you have other questions about it. Be sure to ask if the claim was denied because of a billing error or missing information. If you think you may want to appeal the decision, ask the representative to go over the process with you or to send you a description of how to appeal. Write the name of the person you talked to, the date, and what was done or decided. Do this for every phone call.Ĭall your doctor's office if your insurance says that your doctor left out information or didn't use the right code. Ask your doctor's staff to fix the error and send the paperwork to your insurance again.Ĭall your employer's HR department if you have coverage from your job. That could convince the insurance company to reverse its decision and pay the claim.įor instance, ask if your employer could send a letter - or place a call - explaining why your claim is valid. If your insurance company refuses to pay the claim, you have a right to file an appeal. The law allows you to have an appeal with your insurer as well as an external review from an independent third party.
You'll need detailed instructions on how to file an appeal and how to complete specific forms. Be sure to ask if there is a deadline for filing an appeal.If you're filing an appeal, let your doctor or the hospital know. Ask that they hold off on sending you bills until you hear back from your insurance company. Also, make sure that they won't turn your account over to a collections agency.Ĭall your doctor's office if your claim was denied for treatment you've already had or treatment that your doctor says you need. Ask the doctor's office to send a letter to your insurance company that explains why you need or needed the treatment. Make sure it goes to the address listed in your plan's appeals process. Ask for a copy of the letter to keep in your files. The first step in an appeal is called an internal review. It begins when you file a complaint to appeal a denied claim. Your claim will get a second look by insurance company employees who weren't involved in the original decision.
If you are in an urgent medical situation, you can request an expedited appeal which requires the insurance company to make a decision within 72 hours.Īfter the internal review, your insurance company will call or send you a letter about its decision. If the insurance company overturns the initial decision, your care will be covered. If it upholds the decision, you still have other options. If you're not happy with the outcome, you can take it to the next level. People who don't work for your insurance company - called an independent third party - will do their own review.
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