Navigating the world of healthcare and insurance can be difficult, but if your health insurance claim was rejected, you still have options. Last week’s blog addressed reasons your claim might be rejected. Here are tips for consumers looking to file a health insurance appeal.
Steps to take for your first health insurance appeal
- Review the denial letter sent by your insurance company, paying close attention to the specific reason given for the denial. Read your health insurance policy to see if it addresses the specific reason for your denial. Review all the rules of your insurer’s appeals process and note any deadlines; you may have a limited time in which to appeal.
- Check to make sure the claim is coded correctly. Sometimes benefits are denied because the doctor’s office has entered the wrong billing code.
- Keep a notebook or a file folder to document all correspondence. Create a log of all your insurance-related calls, including date and time of call, name and title of the person with whom you spoke, and all the details of the conversation.
- Keep copies of all letters received, including denial letters, explanation of benefits letters, bills from your provider, medical records, and letters from your physician. Get a copy of your plan’s full benefits language, sometimes called the “evidence of coverage,” as well as the detailed guidelines that explain what the company considers medically necessary.
- Ask your doctor to write a letter discussing your specific case and why your treatment is medically necessary. Find articles about your medical condition or treatment published in peer-reviewed clinical journals and send them to your insurance company. Include any pertinent medical records, such as pathology reports or names of chemotherapy drugs you have already tried.
- Write your appeal letter. Be clear and firm, and focus on facts rather than opinions. State that you will continue to pursue the appeal until the claim is paid or care is approved. Keep a copy of all documents for yourself, and send your appeal packet to the insurance company via registered mail. Follow up with your insurance company to track the status of your appeal, taking notes on each call.
Steps to take for your second health insurance appeal
- If you are denied a second time, you can file a second appeal, which will typically be reviewed by a medical director at your insurance company who was not involved in the original claim decision.
- Read the second denial letter carefully. It may ask that you submit specific information that was not received with your first appeal letter, and it may ask you to send a new packet to a different person.
- Notify your doctor of the second denial, and gather any new information that is needed. Follow your insurance company’s instructions carefully, paying close attention to all deadlines. Keep copies of all information and letters, and send the new packet via registered mail.
Steps to take for your third health insurance appeal
- If your appeal is denied for a third time, you are eligible to ask for an external review from an independent, third-party reviewer. The external review board is typically made up of nurses, attorneys, and doctors who specialize in the specific procedure you are asking the insurance company to cover. The board cannot override your insurance policy guidelines, but it can determine whether a specific treatment is medically necessary.
- Make sure you understand and follow your health plan’s internal appeal process and the external review program’s procedures and requirements. Also verify that you’ve exhausted your health plan’s internal appeal procedure before asking for an external review.
The Affordable Care Act provides for federal grants that help states start or strengthen consumer assistance programs to assist consumers with appeals and help them understand their health insurance rights.
Notices from your insurer should give you contact information for the consumer assistance program in your state, but you can also find a list at www.healthcare.gov or call your state insurance department.
If your insurance plan is through your employer and you believe you have been denied a health benefit inappropriately, you can contact a benefits adviser at the U.S. Department of Labor’s Employee Benefits Security Administration website or by calling 1-866-444-3272.
A Chicago-based writer and editor, Eve Becker writes about personal finance, health and other topics. She is a former managing editor of Tribune Media Services.