How to Handle a Denied Medical Claim

Medical claims get denied for many reasons, including lack of information, benefits not covered, benefit exhaustion or the service provided did not meet medical necessity criteria. When your medical claim is denied, you have the right to an explanation of the denial that you can understand. You also have the right to appeal the decision. With each claim denial, your insurer will send an Explanation of Benefits that details the claim, what was paid, what was denied and the reason for denial.

Instructions

• 1

  Read the Explanation of Benefits (EOB) and claim denial letter very carefully to determine the reason for the denial. The denial reasons will be listed on the EOB. You may also get a denial letter with a detailed explanation of the denial reason. The EOB and letter also will contain information on how to appeal the decision.

• 2

  Call the number on the back of your medical ID card or the number on the EOB to speak to a representative about your claim denial. If you don't understand the information on the EOB and letter and need a clear layperson explanation of the denial reasons, the representative can help you understand how claims were paid, if part of the claim was paid, and if the denial was due to an administrative or clinical reason.

• 3

  Send any missing information to the insurance company that may have caused the denial. For instance, if the submitted claim is missing details such as your Social Security number, procedure codes or amount charged, the claim may get rejected and denied for lack of information. To get the claim paid, resubmit the claim with all the required information.

• 4

  File an appeal by mail or by calling the insurance company. Gather supporting documentation, including medical records, correspondence and doctor's notes to substantiate your position. Insurance companies do make errors and some decisions about care are subjective and need to be considered on a case-by-case basis instead of following standard denial criteria. Someone not involved with the original care decision will review your claim upon appeal.

• 5

  File second- and third-level appeals if the original denial continues to be upheld after each appeal. Most health insurance plans offer at least two levels of appeal, each handled by different reviewers with no previous knowledge of the prior decision. You also may have an option to take the denied medical claim to arbitration where both you and the insurer can present your side and an independent party can make a final binding determination.