How To Appeal A Health Insurance Claim Denial- Steps Involved

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Your Health Insurance Claim Denial can be Appealed!

If you are under a health insurance policy, whenever you receive medical treatments, services or medications, your healthcare provider will submit a request for payment to your health insurance company. The insurance company will review your claims and decide if your health plans cover the services or not and how much the company will pay to the hospital.

However, there are some situations where the health insurance company would deny a claim or pay less than you expected. If you are in these shoes, relax! There is a health insurance claim appeal process that you can follow to have your health insurance company pay all the necessary bills.

This is why in this article you will be; learning how to appeal a health insurance denial, the reasons why health insurance claims are denied and the steps to appeal a health insurance claim denial. Just read along to get full details.

To start with, let’s take a quick look at what a health insurance claim is.

What is a Health Insurance Claim

A Health Insurance Claim is a request for payment submitted by either you or your health care provider to the health insurance company you use after you have received treatments, services or medication. Once your insurance company accepts the claim submitted, they will cover your medical bills in full or part, depending on your health policy.

However, there are cases where you are denied health insurance claims and your insurance company will refuse to pay or reimburse money for the treatment. But you need not worry as there are ways in which the claims denied can be appealed.

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Why Would A Health Insurance Claim Be Denied?

Knowing your health insurance claim denial reasons is important because it tells you whether you need to appeal the insurance denial or not. If eventually, your appeal succeeds, your insurance company will be left with no choice but to pay for the claim. To sum up, here are a few reasons why health insurance claims are denied;

  • There could be problems in the medical billing process or missing or incomplete information in the claim documents that have been submitted.
  • Your claim may not be covered by your health insurance policy, or the procedure may not be seen as medically essential.
  • Your plan’s coverage limits might have been reached.
  • When your health plan required “in-network” doctors, you might have used out-of-network services or taken your health insurance out of the country.
  • The procedure is regarded as experimental or under investigation.
  • Your health insurance claim wasn’t filed on time.

Ways to Appeal a Health Insurance Claim Denial

Claim denied by insurance can be appealed in two ways; an internal review insurance appeal or an external insurance appeal.

Internal review

An internal review appeal, often known as a “grievance procedure,” is a request that your insurer review and reevaluate their choice to decline coverage for your claim. An internal appeal is something you are allowed to do to settle the insurance dispute or insurance denial. Basically, in this insurance appeal, you are requesting a fair and thorough review of the decision made by your insurer by doing.

External review

You have the right to initiate an external review appeal if your insurer keeps refusing to provide coverage for a disputed claim. This is handled by an unbiased third party. This type of insurance appeal is known as an “external” process because your insurer will no longer have the final say in whether or not to pay for a claim.

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Steps Involved With Appealing a Health Insurance Claim Denial

The following are the steps to appeal a health insurance claim denial;

●     Find out why your claim was denied

The first question that should come to your mind when you experience denial of insurance claims is; ‘why was my health insurance claim denied’?. This should then prompt you to read thoroughly the notification from your insurer, including any Explanation of Benefits provided.

Legally, your health insurance company is required to notify you in writing and explain the reasons you are denied health insurance claims. This must be done within 15 days if you are requesting prior permission for treatment. It must be done within 30 days if you have already received medical services and within 72 hours for urgent situations.

If the explanation provided in the notification isn’t clear or satisfactory, try getting in touch with your insurance company to find out more. Importantly, ensure to keep records of all conversations with your insurance company.

●     Consult Your Doctor

You can as well contact your healthcare provider and ask them why your insurer denied your health insurance claim. It might be a minor issue like your provider office inputting the wrong payment code or other minor issues.

Therefore, request confirmation from them that the insurer received the correct medical code and they should inform the insurer that the treatment provided is medically necessary.

Also, gather information from your healthcare providers such as a copy of the claim form sent, health records dates and a letter from your doctor requesting that your claim be granted based on their assessment of your health situation.

●     Learn how and when to appeal

It is important you know how to appeal insurance denial and when to do it. Do this by reviewing your health insurance policy. In there, you will find the steps required for appealing, the deadlines to file an insurance appeal including how and where to submit the appeal. You can as well consult a health insurance claim denial attorney for advice as to how best to make your insurance appeals. However, if you don’t have your insurance policy manual, phone or e-mail your insurer to get it.

●     Write and file an internal appeal letter

Write an appeal letter containing all the crucial information, facts, and supporting evidence required to support your claim. Be as accurate, precise, and polite as you can. Avoid using abusive, aggressive, or threatening language or tone.

●     Get Feedback from Your Health Insurance Company

Evaluate your policy to find out how long it will take your insurer to consider and decide on your appeal. If you have any questions or after that period has passed and you are still unsure, get in touch with your insurance provider.

●      File an external review appeal if necessary

If your internal review appeal was denied and your health insurance claim remains unapproved, proceed to file an external review appeal.  This must be filed within four months after the date you received a final notice from your insurer that your claim was denied.

You can consult your insurer or a health insurance claim denial lawyer on how to officially file an external review.

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How Long Can You Appeal a Claim Denial?

When you are appealing a health insurance claim denial, you have a maximum of six months to file an internal appeal after learning that your claim was denied. For external appeal, it must be done within four months following the date your insurer notified you that your claim was denied.

How Long Does a Health Insurance Company Take to Decide on a Denied Claim?

After filing an appeal you should expect a response within the following number of days. However, the timeline depends on your state’s law.

  • 30 days If your internal appeal relates to a service you haven’t yet received
  • 60 days If your internal appeal relates to a service you’ve already received
  • 45 days for standard external reviews.
  • 72 hours for emergency external review.
  • 7 calendar days for services or treatments that are requested as experimental or investigational.

Frequently Asked Question

How Often Do Insurance Companies Deny Claims?

For the majority of Americans, most insurance claims get approved. According to the American Academy of Family Physicians, the health insurance industry averagely denies 5% to 10% of insurance appeals. Therefore, about 90 to 95% of claims get approved every year.

What Happens When a Health Insurance Claim is denied?

If your health insurance claim was denied, it means that your insurance company will not pay for your medical treatment or services or pay little compared to your expectations.

However, if you feel that your policy covers more than the insurance company has paid, you can file an insurance appeal. You can also write a health insurance claim denial appeal letter asking for your health insurance claim rejection reasons.

How Many Claims Are Allowed in Health Insurance?

You can file as many health insurance claims as possible.

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