How to Get Insurance to Pay When it Is Denied?

When your health insurance company denies payment of a medical bill, you may find yourself scrambling to come up with the funds to pay the debt. If you feel the insurance company has denied a bill that should have been paid under the terms of the policy, you can appeal the decision. Someone at the company will review your claim, and you may succeed in having the decision reversed.

Things You'll Need

• Copy of your insurance policy
• Copy of itemized bill
• Denial letter or statement

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Instructions

• 1

  Review the copy of your insurance policy. Many policies are long and make for boring reading, so it's possible you overlooked some section of the policy in your initial reading. Look for policy language that refers to your situation. For instance, if the insurance company denied a service because you didn't get approval from them prior to having the service, you may be able to overcome this objection if you can prove your situation was an emergency that didn't allow time for approval. If you saw a doctor who wasn't part of the insurance company's list of providers, you may be able to prove that this doctor was the only one who could provide the service you need.

• 2

  Double-check the insurance company's denial letter to make sure the doctor or hospital filed the original claim correctly. Insurance companies use alphanumeric codes to list the services provided and the diagnosis given. One letter or number misplaced could result in wrong information. Double-check your information also, especially your date of birth and medical insurance number. If you find a mistake in the original claim, ask the provider to file a new claim with the correct information.

• 3

  Write a letter to the insurance company appealing the denial. State why you feel they should pay your claim. Use facts to support your claim and provide details such as the exact service you received, the name and address of the provider, and the dates of the service. Refer to specific provisions in your insurance policy that you feel point to their obligation to pay the claim. Send the letter to the address on the claim for appeals.

• 4

  Enlist your doctor or other provider to help you. If the insurance company continues to deny your claim, saying the service isn't necessary, ask your doctor to write a letter to the insurance company stating why you needed the service.

• 5

  Follow up on your appeal. Ask the insurance company what you can do to expedite the review process. Ask the status of your claim and who is handling it. Offer to provide more information. Remain polite. Make note of the date, time and name of the person you speak to and keep a log. Refer to these conversations in any follow-up appeal letters.

• 6

  Contact your state's insurance office. If your insurance company continues to deny your claim, and you feel the service should be covered, contact the state office that overseas health insurance. This may be an insurance commissioner or ombudsman. Explain your situation and ask for help to resolve the issue.