How to Appeal an Insurance Claim Denial
Health insurance contracts can be difficult to read and understand. Customer service representatives may not always provide correct or complete information. So how do you appeal a claim that is denied? The answer to this question is relatively simple. The preparation of your appeal can be time-consuming but knowing what to do can simplify the process. Listed below are the essential steps to file an appeal when your health insurer denies a claim.
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Instructions
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Submit your request in writing. Although customer service representatives may offer to assist you over the phone, it is important to have a paper trail. Always write down the name and title of every representative that you speak with regarding the matter and include this in your written appeal. Although a representative may provide verbal assurance that the matter will be investigated, it is always better to have written documentation that an appeal was filed.
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Provide a copy of the denial notice that prompted your appeal, along with your letter. Notices may be in the form of a letter or Explanation of Benefits Statement received from the insurance company. Providing a copy will allow your insurance company to forward your appeal to the appropriate department for review. For example, a denial may be issued because your insurance company did not feel the service was medically necessary. In this instance, your appeal needs review by a licensed medical professional. However, if you are denied coverage for something that your insurance company states is not in your contract, a medical review is not required.
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State the reason for your appeal. You may feel that you should not have to pay for a service but the basis of your appeal is the reason why. Were you misinformed? Were you unable to contact your insurance company prior to having the service provided? Was it an emergency? These circumstances are important to include. You should also indicate if you have been billed by the provider of the service.
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Provide documentation to support your reason to overturn the denial. Review your contract and reference applicable information. If you were misinformed by a customer service representative prior to the service, indicate the name of the representative and the date of the call. It is also helpful to provide medical records if applicable.
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Contact your insurance company if you have not received notification that your appeal was received after 10 business days have passed since you mailed your request. You may want to send it via certified mail and request a signed receipt.
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Keep a copy of everything that you send to your insurance company. If your appeal is denied you may be able to file a second appeal and provide additional information. If you are notified that the decision is final, you may want to contact your state's Department of Insurance (DOI) for assistance. It is important to have documentation to provide to the DOI.
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Tips & Warnings
Only state the facts in your appeal. Save your gripes for your therapist.
Do not procrastinate. If appeals are not filed within a specific timeframe, your insurance company could refuse to review it.
