Guide to handling health insurance claim denials

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Health insurance companies may deny claims for many reasons, including billing errors, clerical mistakes, seeking care outside of a plan’s network, and not receiving the necessary preauthorization.

It’s every patients’ worst nightmare: You undergo an expensive medical procedure, and your health insurance company denies the claim and refuses to pay it.

You can appeal the denial, but successfully appealing a claim requires a willingness to fight hard for what you feel is due to you.

“I tell people all the time, ‘Please do not give up.’ Because they get sick and tired of this, they say, ‘I can’t handle this, I can’t do it,’” says Adria Goldman Gross, CEO of MedWise Insurance Advocacy and author of “Solved! Curing Your Medical Insurance Problems.”

Read on to learn more about how to get a health insurance plan claim paid after it has been denied.

Why are health insurance claims denied?

Health insurance claim denial reasons vary. Before you dispute a denial, make sure you have a solid case.

“You have to look to see what is covered and what is not covered in your policy,” Gross says.

Here are common reasons when a health insurance company may deny a claim:

A patient sees a provider or visits a facility that isn’t in a health plan’s network.
A health plan doesn’t cover the procedure, test, drug or service.
A provider fails to submit the correct claims information to the health insurer.
A clerical error.
A provider’s office doesn’t provide enough information to the health insurance company.
A doctor doesn’t get the necessary preauthorization for a medical service.

Gross says similar claim-denial issues crop up for both commercial health insurance plans and Medicare Advantage plans. Fewer issues tend to occur with Original Medicare and Medicaid coverage.

Key Takeaways

Health plan members can appeal denied health insurance claims. The appeals process often involves internal review and may include external review of claims.
Getting help from providers, including a letter explaining why the insurer should approve the claim, is crucial to getting a denial overturned.
When writing an appeal letter, stick to the facts and don’t let your emotions get the better of you.
You can request an expedited appeal if you need medical care or the matter is urgent.
Health plans may also reject a claim if a doctor’s office included the wrong billing code when submitting the claim. A provider can often resubmit a claim with the correct information to rectify the issue.

How to appeal health insurance claim denial

Don’t panic if your health insurance claim is denied. You still will have the right to appeal the decision.

Your first step is to find out why the claim was denied. The decision to deny should be stated in the explanation of benefits form you receive. If you’re confused or need more details, call your insurer.

Once you understand why the insurer denied the claim, take a look at your health insurance policy. It will explain exactly what is and isn’t covered under your policy.

If your research has convinced you that your claim shouldn’t have been denied, prepare to appeal the decision. First, learn the deadlines for filing an appeal. Then, gather any documents pertinent to the claim that can help your case, such as a letter from the doctor who treated you explaining why the treatment was necessary.

“You really need to have strong letters from the medical providers on why this claim should be paid,” Gross says.

She notes that these letters should come from the doctors who were actually responsible for your care, not just a physician you know who has an opinion on the matter.

You can also write your own concise letter about why the claim shouldn’t be denied. Stick to the facts of the case. You might want to send the appeal via certified mail so you have proof it was received.

Follow up if you haven’t heard back from the insurance company within 10 days.

The insurance company will have an internal appeal to review the situation. If your appeal was denied, you can file a second appeal. And you be able to file appeals beyond that, including an external review from an independent third party, depending on the health plan’s policies.

If you receive a denial letter repeatedly, Gross suggests reaching out to your state’s department of insurance, attorney general’s office or office of consumer affairs or consumer assistance program. However, she urges you not to take this step until you have suffered through multiple denials.

“They are not going to even want you to bother them until you are at that point,” Gross says.

How to write an appeal letter for denied health insurance

When you file an appeal letter, make sure you simply state the facts. Be as professional and courteous as possible, leaving out anger and other emotions.

While writing your own letter can help your case, it’s no substitute for getting letters from the physicians who treated you that state why your claim should be paid, such as if a treatment is medically necessary.

After you receive multiple denials, you can reach out to:

Your state’s department of insurance, attorney general’s office or office of consumer affairs. If your health insurance is through an employer that is self-insured, you will have to appeal the decision through the U.S. Department of Labor.
A lawyer
A service, which works with elder law and personal injury attorneys to fight on your behalf

Sample letter for appealing a health insurance claim denial

Wondering what you should write when appealing a health insurance claim denial? Following is a sample letter for appealing a health insurance claim denial:

[Your name]

[Your address]

[Your city, state, ZIP]

[Your phone number]

[Date]

Attn: Director of Claims

[Name of insurance company]

[Insurance company address]

[City, state, ZIP]

Re:

Patient: [patient name]

Policy: [insurance policy number]Insured: [name of patient or insured person]Treatment dates: [admission date] – [discharge date]Amount: [total charges]

Dear [Mr./Ms./Director of Claims name, if available],

You recently denied a claim on the grounds that the care provided by [name of provider] on [date of services] was not medically necessary.

Denial of this claim was not justified and I am appealing the denial. The explanation of benefits did not give adequate information to establish the validity of this decision. Therefore, please provide the following information to support the denial of this treatment.

Please furnish the name and credentials of the insurance representative who reviewed the treatment records. Also, please provide an outline of the specific records reviewed and a description of any records that would be necessary in order to approve the treatment.

Also, please furnish copies of any expert medical opinions that have been secured by your company regarding treatment of this nature so that the treating physician may respond to its applicability to [my/this patient’s condition].

Please review this claim again. The information is correct [or has been corrected] to reflect the appropriate diagnosis and treatment. If you need further information or a medical report, please inform me within 10 days.

I can be reached at the following telephone number(s):

Daytime: [your phone number]

Evening: [your phone number]

Thank you for your prompt attention to this matter.

Sincerely,

[your signature here]

Frequently Asked Questions

What should be done if an insurance company denies a service stating it was not medically necessary?

Once a claim has been denied as “not medically necessary,” it’s your job to build a case that changes the insurance company’s judgment about the claim.

The best way to do this is to get a letter from the all the health professionals who treated you stating why your treatments were medically necessary.

“Get multiple letters, get strong letters,” Gross says.

Also, ask your insurance company what type of other documentation it might require that can bolster your case that the service was medically necessary.

How long does an insurance appeal take?

Typically, a health insurance appeal can take up to a couple of months. However, if you’re waiting for treatment, the process may be expedited and take only a month or so.

In some cases, you can request an expedited appeal process, which might take only a few days before it is decided.

What do you do if health insurance denies a claim?

Appeal the decision if you feel the denial is wrong. Once you appeal your denial, the insurance company will respond. It may deny the appeal, forcing you to appeal again, possibly multiple times.

“You need to get to your final denial, where the insurance company says to you, ‘This is your last appeal — we’re not going to accept this any longer,’” Gross says. “When you get to that point, that’s when you go to the government.”

Just remember that in some cases, your appeal may be doomed to denial, no matter what avenues you use to try to get the claim approved.

“If it says right in the policy, ‘You are not covered for this, this and this’ — you are not going to win that case no matter what,” Gross says.

What is an expedited appeal?

An expedited appeal takes place when you ask the insurance company to speed up the process, usually because you are awaiting medical care or have some other urgent need for a quick resolution.

An expedited appeal is often resolved within 72 hours.

What’s the difference between denied claims vs. rejected claims?

Typically, a denied claim results from something that violates a health plan’s rules. Not seeking a preauthorization is an example of something that triggers a denied claim. Failing to provide adequate documentation of the claim is another example.

Rejected claims usually are the result of a simple error in the health provider’s office. Most often, this happens when the provider submits an incorrect billing code. The problem can be fixed by the provider resubmitting the claim with the right code.

Chris Kissell

Contributing Researcher

Chris Kissell is a Denver-based writer and editor with work featured on U.S. News & World Report, MSN Money, Fox Business, Forbes, Yahoo Finance, Money Talks News and more.