Getting everything you deserve from your health-care insurance sometimes requires putting up a fight.
If you receive notice that a claim for health-care expenses was denied, don't just accept the decision. Health-care providers frequently overturn claim denials. By following the steps below, you may be able to reverse your insurer's denial and improve your own financial situation as a result.
Investigate the denial:
Start by figuring out why your claim was denied. Insurers usually provide a basic reason for their decision in the Explanation of Benefits (EOB) that accompanies their denial letters. You can get a full explanation by calling the customer-service number on your insurance card.
Claim denials often stem from simple administrative errors, so there's a chance a phone call will be all that's needed to overturn a decision. Before you pick up the phone, gather relevant paperwork, including your EOB.
Once you've got a customer-service agent on the line, find out whether your insurer deems your medical care not medically necessary or not covered by your plan. If you still believe your claim is legitimate after hearing your insurer's explanation, get details about its appeal process, including potential timelines and required paperwork.
Be polite, but don't hesitate to press for more details if the customer-service agent simply repeats what you already knew or confuses you. Starting with this phone call, take careful notes on any communications with your insurer, including taking down the name and phone number of the person with whom you speak. This information could come in handy as the claims process progresses.
File an appeal:
Now it's time to make your case. You should have a document, labeled Evidence of Coverage or Summary Plan Description, that explains what your plan covers and what it doesn't. (Many large insurers, like
, post these documents online.) Read the document carefully, looking for any information that's relevant to your situation. For example, if your insurer says you failed to get prior authorization for certain medical care you received, check your plan documents to make sure prior authorization really was required.
When you compile your appeal, use this information to show that your claim is legitimate. Along with your appeal, include records of any care you received that's relevant to your claim.
If your insurer argues that your claim isn't based on medical necessity, ask your doctor to write a letter explaining why it
medically necessary. You can also look for, and cite in your appeal, medical studies that support the necessity of the medical care you received. Likewise, if this care is covered by Medicare or another government-sponsored insurance program, mention that in your appeal.
Seek an external review:
If your first appeal is denied, don't get discouraged. Your plan may allow for another stage of internal review, likely administered by a panel of individuals who haven't previously seen your case. This process may include a consultation with a physician and possibly your own testimony.
Once you've exhausted your plan's internal-review processes, it's time to seek a higher authority. If you're covered by an employer-sponsored plan, ask HR whether the plan is self-funded. If so, your only recourse is the court system.
If the plan is not self-funded, determine whether your claim is eligible for review by your state's
. (External-review procedures vary widely from state to state and a few states only review certain types of plans.) If so, ask the state to initiate an external review of your appeal. If you're confident in your case, this process may be worth pursuing: Nearly half of the appeals that reach external review are successful, according to the
Kaiser Family Foundation
, which offers a comprehensive guide to navigating the appeal process.
Zack Anchors is a freelance writer from Portland, Maine.