A medical facility typically submits a claim to your health insurance company after receiving treatment, services, drugs, or medical supplies. The insurance company reviews the claim and decides whether your health plan will cover the service and how much the provider will be reimbursed. This decision affects how much you pay.
The health insurance company may deny the claim or pay much less than you expected. But if you believe your health plan should pay for this care, there is a health insurance appeals process.
What is the health insurance claim?
A health insurance claim is a request for payment by you or your health insurance company after you or your health care provider receive services, treatment, drugs, or medical supplies that you believe are covered by your insurance plan. An accepted claim covers all or part of the bill and reimburses the provider or patient for those costs.
Your insurer may deny the request and refuse to pay or pay for the service or treatment. The Kaiser Family Foundation estimates that in 2020, 18% of claims for in-network health insurance were denied by the Affordable Care Act marketplace health insurance companies.
You can be sure you did everything right when you put this health insurance claim together. You filled out every field on the claim form, submitted an itemized bill for each service, and wrote a cover letter summarizing your concern.
But apparently, that wasn’t enough for your insurance company. They denied your claim in the business district — okay, borderline rudeness — letter. Now, he has several thousand dollars in medical debt and no clear plan to pay it off.
Or maybe you don’t. Your rejection letter isn’t the end of the story—it doesn’t have to be, anyway. If you persevere and go to court properly, you may be able to pay this claim, at least in part.
How do I file for a health insurance claim denial?
You always have the right to appeal a denied health insurance claim. It takes work, but if it means wiping out a big bill, it’s worth it.
Follow these steps to make an internal appeal to your insurance company. With any luck, that will be the end of it. It will not be necessary to apply externally. But if you do, there are instructions for that too.
1. Review the Denial Letter from the Insurance Company
Health insurance companies do not deny claims without explanation. They send a letter explaining the reason for the denial.
The most common reasons insurance companies deny claims are:
- The provider made a billing or coding error.
- The insurance company made a mistake with the clergy.
- You purchased service from an out-of-network provider.
- The first claim was incomplete due to missing or incorrect paperwork.
- The suit did not include enough information for the insurer to decide.
- The insurer has agreed that the service or procedure is not medically necessary.
- Your health insurance plan did not cover the service or the system.
- The insured denied this claim during the previous authorization process. This is also known as prior authorization. Health insurers use this requirement to limit payment for unnecessary medical care. Or you received care that required pre-authorization without it.
Your first step is to review this letter. Although not very detailed, the reason for the denied claim and any explanation can offer a road map for your appeal.
Call the insurance company’s claims processing department if the letter doesn’t contain much useful information. The number should be on the denial letter.
Ask them to turn away from them so that we may rob them of their presence for years (in nothing). Ideally, get this verbally from the customer service representative and in writing, so you have an official record from the company. In any case, ask for a written copy of the explanation.
If the company denied the claim for a straightforward reason, such as a transposed number in the account code, the claims representative could offer to fix it on the spot. In that case, you can pause your application until you receive a confirmation by mail that the insurance company has accepted your claim. But don’t count on being so lucky.
2. Collect documents
Then gather documents to support your claim. The documents you need depend on why the insurance denied your claim.
Go to the hospital or doctor’s office and request a detailed bill for the services you receive. This document is more complicated than explaining the benefits you receive from your insurance company.
If the insurer denied the claim due to a billing error or inaccurate paperwork, ask them to double-check that they entered all the relevant information and the correct service codes. For faster service, if possible, have everything sent to you via a secure electronic messaging system.
If the insurer denied the claim because it decided the procedure or service was not medically necessary, ask your provider’s office for a letter of medical necessity. This letter should explain why you need the system or assistance and clarify that the licensed health care provider recommends it.
Additional information that may support a claim of medical necessity includes:
- A note from your supervisor stating that your condition prevents you from performing your duties
- Peer-reviewed studies showing the benefits of a newer or alternative treatment not covered by your insurance company
- A second opinion from another licensed medical provider that approves your treatment plan
- Medical records that provide more information about your symptoms and how your condition has changed over time
3. Keep detailed notes
Keep detailed records of every interaction with your insurance company, healthcare provider, and anyone involved in your claim. For each interaction, record:
- Name and title of the person you are talking to
- Their contact information, including phone number and email address
- What do you discuss in as much detail as possible?
- The outcome of the conversation, including the next steps for you and the person you’re talking to (or their employer).
Save these notes to a folder on your computer or phone. Shortly after taking the handwritten notes, transcribe.
4. Write a cover letter
After collecting all the necessary documents, write a letter of application to each other.
Above the body of the letter, include the following:
- First claim number
- Insurance identification number
- Date or dates of medical care
- Name of the insured
- Postal address of the insured
- Birthday of the insured
The letter’s first paragraph states that you want to appeal the disputed claim and clearly states why.
Use the rest of the letter to explain why you are applying if the insurer decided that your treatment was not medically necessary; list why it was not. Always point to supporting evidence, such as a letter of medical necessity or copies of relevant plan documents. Include copies of these supporting documents with your application.
Avoid emotional language and unnecessary information. If this applies to your claim, you can discuss the issues with the insurance company’s preliminary review process but avoid personal attacks or rants. End the letter by asking the insurer to accept your claim and pay your medical expenses.
Contact your insurer within ten days of applying to confirm they have received everything. Then contact your healthcare provider and let them know that you plan to wait for the insurance company’s decision before paying any costs.
5. Wait for the decision of the insurance company
Don’t expect your insurance company to process your claim right away.
Even if it is an open amendment, they must review your documents and letter and determine whether to reverse the denial. This can take up to 60 days, while many appeals are resolved within a few business days.
Please pay attention to the letter from your insurance company explaining their decision. Feel free to call if you don’t see anything in a few weeks. But this call is likely under internal review, and the powers haven’t decided yet.
What to do if your health insurance application is denied?
If the internal appeal process results in another denial, go to the next step. This is an external appeal, also known as an exterior appeal.
External referrals are usually linked to an independent third party that assists consumers with insurance claims and applications. Depending on the situation, you can:
- Hire an independent claims adjuster or health insurance attorney through the Union of Claims Assistance Professionals.
- File a complaint with your state insurance or insurance commissioner’s department.
- Access the non-profit consumer assistance program for insurance customers – check your explanation of benefits for programs that serve your area.
- If you have health insurance through a self-insured employer, file a complaint with the US Department of Labor.
If you hire an independent third party to help you with your claim, you may have to pay them a portion of the amount they help you with. If you file a complaint directly with your state insurance department or the US Department of Labor, you won’t have to pay anything out of pocket. But professional claims adjusters and attorneys can increase the likelihood of success.
Medical expenses are expensive. Indeed, it is costly. Even after a successful application, you can get hundreds or thousands of dollars back in your pocket.
Making a health insurance call takes time and persistence, but it’s not overly complicated. With the proper supporting documents and a strong challenge letter, your insurer may reconsider.
That said, taking your denied claim as a sign of a change in health insurance coverage is good. Visit the Affordable Care Act market to see if you’re eligible for an individual health plan. Or talk about your choice to cover through your boss.