How to Appeal Insurance Denials

When it comes to insurance claims, organization and knowledge are your best weapons in the fight against denial of coverage. Most of the time, proactive measures such as taking the time to read and understand your policy and getting pre-authorization before receiving care will reduce the likelihood of claim denials. In the event this should happen, however, the terms of the Employee Retirement Income Security Act of 1974 state you have 180 days to appeal the denial. This allows plenty of time to think before you act and follow correct procedures in the appeal process.

Things You'll Need

• Summary plan description
• Notebook
• File folder
• Hospital/doctor bill

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Instructions

• 1

  Locate and read the Summary Plan Description (SPD) for your policy, making special note of the procedure your insurance company outlines for filing a denial appeal. According to the U.S. Department of Labor, this document must contain specific information on how and where to file your appeal, as well provide a point of contact if you have questions. A successful appeal depends in large part on following proper procedure so before going any further, make sure you fully understand the process.

• 2

  Gather documents you need when filing your appeal and place them in a central location, such as a file folder. Include your SPD, original billing statement, denial letter and a notebook or note paper.

• 3

  Establish single points of contact to assist you in gathering the documents and information you need to file your appeal. Refer to your SPD or denial letter for the name and number of your insurance company point of contact. Call the billing department of your hospital or doctor's office to get names and phone numbers for treatment and/or billing questions. Record this information in a notebook.

• 4

  Talk to your hospital or doctor's office point of contact. Ask for information that may support your claim, such as a statement or notes from your doctor substantiating the necessity and/or cost of treatment. If your original bill is in summary form, ask for an itemized copy. Review the bill carefully and if you find errors, such as charges for services you did not receive, ask for an adjustment and a new bill to submit along with your claim.

• 5

  Compose and send an appeal letter requesting a formal review of your claim. Make sure to follow the process exactly as your insurance company requires and include all supporting information. As an extra measure, consider sending the letter via certified mail and request a return receipt.

• 6

  File a second appeal, and if necessary a third, if your insurance company issues another denial. Once you exhaust internal levels of appeal, your insurance company, by law, must allow an impartial third party to review your claim and issue a final decision.