How to Appeal a Health Insurance Denial

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A health care provider often sends a statement to your insurance company when you receive treatment, care, medication or medical supplies. The insurance company reviews the claims and decides if your health plan covers the service and how much they will reimburse you for. That choice affects how much you pay.

The health insurance company may deny the claim or pay less than you expected. But there is a way to apply for health insurance if you believe your health plan should pay for that care.

What is Health Insurance?

A health insurance claim is a request for payment that you or your health care provider makes to your health insurance company after you receive treatment, care, medicine or medical supplies that you believe are covered by your insurance policy. An approved copay covers all or part of the bill and reimburses the provider or patient for these costs.

Your insurer may deny your claim and pay or reimburse you for services or treatment. The Kaiser Family Foundation estimates that 18% of in-network insurance plans will be rejected by health insurance companies in the Affordable Care Act market in 2020.

Why Can a Health Insurance License Be Denied?

A health insurance company can deny claims for many reasons, including:

  • The support or service is not considered necessary or appropriate.
  • The plan does not cover treatment, support, drugs or goods.
  • The health care provider is not in your plan’s network.
  • Your insurance requires a prior authorization or referral from your primary care physician.
  • These drugs are considered investigational or experimental.
  • Your employment has ended or you are no longer registered with the insurer.
  • Paperwork or data entry errors prevented the claim from being processed properly.
  • The decision was not delivered on time.

Claims rejected versus rejected

The word “rejected” is actually different from what is “rejected”. Here are the differences:

  • A denied claim is one in which the insurer finds that it is not paid. These claims may not be paid due to serious errors or breach of the sponsor’s contract.
  • A denial decision contains one or more errors that were discovered before the application could be processed, usually because there was insufficient or incomplete information on the application form.

Patients or providers are usually notified of the objection via email or e-mail Explanation of Benefits or Electronic Mailing Advice. Insurers often explain the reason for denying a claim when they send the denial to the issuing party. Most denials can be appealed.

Denied claims must be processed and resubmitted by you or your health care provider. If denied, a denied claim can often be appealed.

What is an urgent request?

You can ask for an expedited appeal if you believe that waiting for a decision would put your health at risk, such as if you need medication urgently or are in hospital.

An expedited appeal is allowed if the appeal time frame would endanger your life or your ability to resume good work. In this case, you can make an internal appeal and an external review request at the same time.

To request an expedited appeal, state on your appeal form that you need to file an expedited appeal and state the health reasons in your appeal letter.

Decisions on urgent expulsion are issued quickly, depending on the urgency of the patient’s health. In most cases, the decision is issued within three calendar days from the first day the appeal was received.

Two Ways to Push a Decision to Deny Health Insurance

There are two ways to appeal a health insurance denial: an internal review appeal and an external review appeal.

Internal comment

An internal review appeal, also called a “grievance process,” is a request for your insurer to review and reconsider its decision to deny coverage for your claim. You have the right to file an internal appeal. By doing this, you are asking your insurer to properly review its decision.

External comment

If your insurer continues to refuse to pay your claim, you have the right to appeal to an external review. An independent person does this. It is called “external” because your insurer will no longer have the final decision to pay or not.

Factors Affecting Health Insurance Denial

Step 1: Find out why your claim was rejected

If you have received notice from the insurer that your claim has been denied, read the letter carefully, including any Explanation of Benefits provided.

Your insurer must notify you in writing and explain why your request was denied within 15 days if you are seeking authorization for medical care, within 30 days for medical care you have already received or within 72 hours for medical care.

If the description is not satisfactory or unclear, try contacting your insurer for more information. Carefully document all communications with your insurance company.

Step 2: Ask your doctor for help

Contact your doctor’s office and ask why they believe your insurance has denied your claim. It can only be a problem if the service provider entered the wrong payment number.

Ask them to confirm that the treatment or care provided was medically necessary and that the correct medical code was provided to the insurance company. Write down everything you learn.

Gather documentation from your provider, including health records, dates, a copy of the claim form they submitted and possibly a new letter from your doctor requesting that the approval be approved based on their opinion.

Step 3: Learn how and when to file an appeal

Also check your health insurance policy, which should show the steps needed to make an appeal, the deadlines for filing an appeal and how and where to send the appeal. Call or email your insurer if you do not have these documents.

Step 4: Write and send the internal complaint letter

Write an appeal letter with all the necessary facts, details and evidence needed to defend your claim. Be as honest, concise and polite as possible. Do not be threatening, hostile or abusive in your words or tone.

The National Association of Insurance Commissioners provides a example of an internal complaint letter.

Step 5: Check with your health insurance company

Check your policy regarding how long you can expect your insurer to review and make a decision on your appeal. If that time has passed, or if you are in doubt, contact your insurance company to see if you have filed an appeal.

Step 6: File an appeal for external review if necessary

If your internal review appeal is denied and your claim is invalid, consider appealing an external review. This must be submitted within four months of the date you received the final confirmation or notification from your insurer that your claim has been rejected.

Ask your insurer how to cover external audits.

Step 7: Connect with your country

If you’re tired of making an insurance appeal, contact your state’s insurance department, attorney general’s office or consumer’s office. States can help you with an external review of the denial of the claim.

How Long Can You Protest If You Say No?

You have up to six months (180 days) to file an appeal within 24 hours of being notified of a denial.

If you submit a written request for an external review, this must be done within four months of the date you received notification or final confirmation from your insurer that your claim has been denied.

How Long Does a Health Insurance Company Take to Decide Claims?

Although the time frame may vary depending on your country’s laws, after making an appeal you should expect to receive a response or appeal decision within:

  • 30 days if your internal appeal is for work you have not yet received
  • 60 days if you are complaining about the service you have already received
  • 45 days of external review
  • 72 hours for a quick review
  • 7 calendar days to apply for experimental or research support or services

Aren’t there any surprises?

Congress passed the No Surprises Act, which went into effect in January 2022.

The law sought to reduce the bite of emergency medical bills for group health insurance and individual health insurance plans. The No Surprises Act prohibits:

  • Extraordinary payments for emergency services from providers outside the network or location and without prior authorization
  • Out-of-network cost sharing, including copays and coinsurance, for emergency and non-emergency services.
  • Out-of-network billing and eligibility for extended care, including pain medications, and out-of-network providers who work online

This policy means that you will not be liable for these types of payments that result in unexpected medical bills. You still need to pay regular out-of-pocket costs, but health care providers and the health insurance company must negotiate coverage for emergency charges. They may have to go through an independent dispute resolution process if they can’t agree, but you as a member will not be affected.

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