How to Fight a Health Insurance Denial

The initial decision the health insurance company makes about your care isn't always final. As a health plan member, you have the right to appeal any determination. Health insurance denials occur for services already rendered or services requested during the preauthorization process. Depending on the health plan and whether the services have already occurred, you receive an explanation of benefits and/or a letter of denial from the health insurance company about the decision. You have the opportunity to fight the health insurance denial through an appeal process or arbitration.

Instructions

• 1

  Find information about your health insurance plan's appeal process. Appeal information may be located on the health plan's website, your explanation of benefits statement, a denial of services letter or in your plan's summary plan description.

• 2

  Review the explanation of benefits statement or denial letter for the denial reason. Note if the denial is for a medical reason, such as lack of medical necessity, or for an administrative one, such as failure to obtain preauthorization for service. If the denial is because the service is excluded, such as cosmetic surgery, you may have a difficult time winning an appeal.

• 3

  Call all doctors and health professionals who were involved in your care or the decision for the treatment. Ask them to write a letter to the health plan, explaining why, medically, you should receive the care. Gather your medical records and any correspondence with the health plan.

• 4

  File an appeal of the denied decision by calling your health plan or submitting the appeal in writing. A legal representative can file for you. Sending any supporting documentation, such as the doctor's letters, your medical records and prior correspondence with the health plan, may help your case.

• 5

  File additional levels of appeals if the first appeal is rejected. Health plans often have more than one level of internal appeal. An external and final level of appeal is available after completing the internal levels. Mandated by federal law, the external appeal is completed with impartial third-party reviewers.

• 6

  Call and ask your health plan if they have an arbitration process. This is a one-time meeting between you, the health plan and an impartial arbitrator. The arbitrator listens to both sides and renders a binding decision that cannot be appealed or heard in a court of law.