Orlando Harmon
If your insurance company refuses to approve or pay for a medical claim, you have the right to appeal the decision. There are multiple levels of appeal, and the appeals process will be outlined in the information you receive when your claim is denied. If your insurer continues to deny you the service or payment for a service, you may have the right to ask for an external review by a qualified outside third party. This means that an organization that is independent of your insurer will review your insurer's denial. If the external reviewer decides your medical service should have been covered, your insurer will have to pay the claim or authorize your care.
| Characteristics | Values |
|---|---|
| If your insurance company denies your claim | You have the right to an internal appeals process |
| You may ask your insurance company to conduct a full and fair review of its decision | |
| You have the right to take your appeal to an independent third party for review of the insurer's decision (external review) | |
| You have up to 180 days (6 months) to file your internal appeal | |
| Your internal appeals must be completed within 60 days of your request | |
| At the end of the internal appeals process, your insurer must provide you with a written decision | |
| If your insurer denies your appeal, you may have the right to ask for an external review | |
| You can appeal and may be able to get your insurer to reverse their decision and agree to pay for at least part of the service you need | |
| Reasons for denied claims | Insufficient information provided with the claim or pre-authorization request |
| You didn't follow your health plan's rules | |
| The service is not considered medically necessary | |
| The wrong billing codes were used by your provider | |
| The bill was filed too late | |
| The service was provided out of network | |
| The service requires prior authorization |
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What You'll Learn
Appealing a denial
If your health insurance claim has been denied, you have the right to appeal the decision. There are multiple levels of appeal and the process will be outlined in the information you receive when notified of the denial. You can start the appeal process by calling your insurance provider and asking for more details about the denial and your appeal options.
Internal Appeal
If your claim is denied or your health insurance coverage is cancelled, you have the right to an internal appeal. You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process and make a decision within 72 hours. If you are appealing coverage for a treatment you have not received, they must make a decision within 30 days. If you have already received treatment, they must reply within 60 days. At the end of the internal appeals process, your insurer must provide you with a written decision. If they continue to deny you the service or payment for a service, this written decision is called a "final internal adverse benefit determination".
External Review
If your insurer denies your internal appeal, you may have the right to ask for an external review by a qualified outside third party—an organisation that is independent of your insurer and not associated with the health plan. If the external reviewer decides your medical service should have been covered, your insurer will have to pay the claim or authorise your care.
Appeal Process
To start the appeal process, gather all the paperwork related to your claim, the service provided, and the denial. This should include the claim denial letter, original bills and documents related to the service, notes and dates from phone calls with your insurance company or doctor's office, any other documents you plan to submit to your provider (such as supporting information from your doctor), and your policy documents. You can then submit an internal appeal directly to your insurance company, asking them to reconsider your case and reverse the decision to deny coverage. You can explain the error and even ask for a full review. You will need to fill out all required forms and write an appeal letter.
Common Reasons for Denial
- Insufficient information provided with the claim or pre-authorisation request
- Failure to follow your health plan's rules, e.g. not getting pre-authorisation for a non-emergency test
- Going outside the provider network for treatment
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Internal and external appeals processes
If your insurance company denies your claim, you have the right to appeal the decision. This right was expanded as a result of the Affordable Care Act. There are multiple levels of appeal, including internal and external appeals processes.
Internal Appeals Process
The internal appeals process involves requesting a review of your insurance company's decision. You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied. If your situation is urgent, you can ask for an expedited review. The internal appeals process typically includes completing any required forms and submitting additional information for your insurer to consider, such as a letter from your doctor. At the end of the internal appeals process, your insurer must provide you with a written decision. If they continue to deny your claim, this decision is called a "final internal adverse benefit determination."
External Appeals Process
If your insurer denies your internal appeal, you may have the right to request an external review by a qualified, independent third party. This means an organization not associated with your health plan will review your insurer's decision. If the external reviewer decides that your medical service should have been covered, your insurer must accept their decision and pay the claim or authorize your care.
It is important to keep detailed records of all information related to your claim, including any correspondence with your insurer and the denial of your claim. Additionally, you should follow the appeals process outlined by your health plan carefully and stay organized by keeping track of each step you take and any relevant documentation.
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When to expect denial
There are many reasons why a health insurance claim may be denied. Understanding the reasons for denial can help you know what to expect when filing a claim.
Firstly, it is important to understand what your health plan covers and does not cover. Services that are not considered medically necessary may be denied. Even if a service is medically necessary, if the wrong billing codes are used by your provider, your claim could be denied. Some health plans also require that a bill be filed within a certain number of days of a test or procedure. If a bill is filed too late, your plan may deny payment for administrative reasons.
Secondly, prior authorization, also known as preauthorization or precertification, is required for some services. If you receive a service before your insurance carrier grants approval, your plan may refuse to pay for it. Insurers sometimes state ahead of time that they won't pay for a particular service during the pre-authorization process, and this is known as a pre-authorization denial.
Thirdly, if you go outside of your provider network, your insurer will likely deny the claim. Exclusive Provider Organizations (EPOs) and Health Maintenance Organisations (HMOs) generally won't cover out-of-network care unless it's an emergency. Preferred Provider Organizations (PPOs) and Point of Service (POS) plans typically include out-of-network coverage, but the deductible and other out-of-pocket costs will be higher.
Finally, if you are no longer enrolled or eligible to be enrolled in the health plan, your claim may be denied. Additionally, if your insurer claims that you provided false or incomplete information when you applied for coverage, they may rescind your coverage back to the date you initially enrolled.
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Reasons for denial
If your insurance company denies your claim, you have the right to appeal the decision. The appeals process will be outlined in the information provided to you when your claim is denied. You may also request an external review by a qualified third party if your appeal is denied.
- Out-of-network services: Unless it's an emergency, most insurance plans will not cover out-of-network care. Exclusive Provider Organizations (EPOs) and Health Maintenance Organisations (HMOs) generally won't cover out-of-network care. Preferred Provider Organisations (PPOs) and Point of Service (POS) plans typically include out-of-network coverage, but the deductible and other out-of-pocket costs will be higher.
- Prior authorization requirements: Some services require prior authorization or pre-certification before your insurance plan will cover them. If you don't obtain prior authorization and proceed with the service, your insurance plan may deny the claim.
- Medical necessity: Even if you and your healthcare provider consider a test or procedure necessary, your insurance plan may not agree and deny the claim unless they receive additional documentation confirming its medical necessity.
- Billing and administrative errors: If the wrong billing codes are used or if the bill is filed too late, your insurance plan may deny the claim for administrative reasons.
- Inadequate information: If there is insufficient information provided with the claim or pre-authorization request, such as missing details about the medical condition being treated, the insurance company may deny the claim.
- Plan restrictions: Some insurance plans have specific restrictions on covered services, and not all plans cover the same services. It's important to understand what your plan covers and whether there are any limitations or exclusions before seeking treatment.
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What to do after denial
If your insurance claim has been denied, you have the right to appeal the decision. This right was expanded as a result of the Affordable Care Act. There are multiple levels of appeal, and the process will be outlined in the denial documents you receive. You should review this letter carefully to understand the reason for the denial and your next steps.
To begin the appeal process, call your insurance provider to ask for more details about the denial and your appeal options. Each insurance company has a specific appeals process, and you will need to follow all the steps carefully. Make sure you find out what forms you need to submit and how long you have to appeal the decision. Keep good records of each step you take, when you took it, and who you spoke with.
If your claim was denied for a particular reason, let your doctor know that you are appealing. You can ask your doctor to write a letter explaining that the service was medically necessary or provide other supporting documents. You can also ask your provider to delay billing until the appeal process is completed. As you prepare to appeal, gather all the paperwork related to your claim, the service provided, and the denial. This should include the claim denial letter, original bills and documents related to the service, notes and dates from phone calls, and any other documents you plan to submit, such as supporting information from your doctor, and your policy documents.
If your internal appeal is rejected, you can submit your case for an external review by a qualified outside third party—an organization that is not associated with your health plan. This means that the insurance company no longer has the final say over many benefit decisions, and the decision of the external reviewer is binding. If the external reviewer decides your medical service should have been covered, your insurer will have to pay the claim or authorize your care.
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Frequently asked questions
If your insurance claim is denied, you have the right to appeal the decision. You can start with an internal appeal, which must be completed within 60 days of your request. If this is denied, you can request an external review by a third party.
There are many reasons why an insurance claim might be denied. Some common reasons include:
- Out-of-network services: If you go outside your provider network, your insurer may deny the claim.
- Missing details or insufficient information: If there was missing or insufficient information with the claim or pre-authorization request, the insurer may deny the claim.
- Not following health plan rules: If you don't follow the health plan's rules, such as not getting pre-authorization for a non-emergency test, the insurer may deny payment.
- Administrative reasons: If a bill is filed too late or there are issues with billing codes, your claim may be denied.
- Services not considered medically necessary: Even if you and your healthcare provider consider a test or procedure necessary, your insurance carrier may deny the claim unless they receive documentation confirming its medical necessity.
According to KFF data, about one in five insured adults experienced a claim denial in the past year. Claim denials are more common for private insurance than for public insurance.
To prevent insurance claim denials, it is important to understand what your health plan covers and what the rules and requirements are. Communicate with your healthcare provider's billing office to ensure they are following the correct procedures and providing the necessary information. If you are considering out-of-network services, check with your insurance carrier beforehand to understand if and how these services will be covered.
