How to Appeal a Denied Medical Claim
Every so often, the insurance company denies a medical claim without giving good reason. You have no idea why they denied the claim. Now, you begin the arduous task of defending the claim to your insurance company. A coding mistake is a common reason for denials. You need to appeal it to the insurance company but you don't know how. Follow the steps below to take the necessary steps.
- Difficulty:
- Moderate
Instructions
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Gather the Claim Information
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1
Notice that the letter you got from the insurance company shows a denied medical claim. This must be a mistake. You went to the doctor and had the work done. So, you decide to appeal the claim denial.
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2
Read your medical policy in order to cite the correct information when you call the insurance company. Your policy will tell you if you are covered. If not, this will save you the hassle of appealing a claim with the insurance company.
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3
Gather all of the information that pertains to your procedure. You mainly need to prove it was a necessity and not a cosmetic choice they denied.
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4
Look up the contact information for the insurance company. It is probably right on the letter you received. See your insurance card if you need to look somewhere other than the letterhead.
Appeal the Claim
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1
Call the telephone number listed on the letter and speak with customer service. They will need to know the claim number and your insurance information. Let them know what occurred with the medical visit.
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2
Listen to what the representative suggests. Most likely, they will take down the information and resubmit it for you. Alternately, they may send you an appeal form to fill out and mail back to the appropriate department. Get your doctor involved if need be. He is very aware of insurance rules and regulations and will be a good person to speak on your behalf.
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3
Contact the state regulatory office in charge of medical appeals if you were denied a second time. The instructions for this are most likely on the letter they sent denying the claim. If not, you will need to call the insurance company's customer service department once more.
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4
Find out if there is a medical review board in your state should a third denial come your way. Check your state's website. Similar to a court proceeding, the decision of the board will be binding.
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1
Tips & Warnings
Now that the rules within insurance companies have become more stringent, the company will deny claims more often for seemingly insignificant typos or other mistakes.
A report by Henry J. Kaiser Family Foundation found that insurers are overruled approximately 50 percent of the time.
Put your appeal in writing. A clear, concise statement is worth more than a lengthy, emotional telephone call.
Double-check your facts. If your explanation contains any inaccuracies (however innocent), it could cost you the right to appeal.
