How to Appeal Health Insurance Claims

Under the Affordable Care Act of 2010, all consumers who are covered under a health insurance plan can appeal a claim. The appeal first goes through the health plan company's internal appeal process, which varies by health plan. If the appeal decision is not favorable, the appeal can go through an external review process for another determination, the Affordable Care Act states. The health plan company will communicate each appeal decision to you in writing.

Instructions

• 1

  Look at the denial reasons listed on the claim's explanation of benefits (EOB) that you received by mail. The EOB details the claim's payment --- fully paid, partially paid or completely denied. If the claim is partially or completely denied, the EOB will list each reason why. If you do not understand the denial reasons, contact your health plan company using the phone number listed on the EOB.

• 2

  Contact your doctor and ask for a written statement that supports your appeal. For example, if the claim was denied due to a lack of medical need, have your doctor write a letter explaining why the care provided was necessary.

• 3

  Gather your medical records from all your health care providers, facilities and hospitals. Collect all correspondence with the health insurance company as they relate to the claim dispute you plan to appeal. Review all documentation to make sure it supports your appeal.

• 4

  Call your health plan company, using the number on the back of your identification card, to file a first-level appeal. You can also submit a written request for an appeal using the address on the EOB. Tell the representative you have supporting documentation, and email, mail or fax it to the health plan company according to the representative's instructions.

• 5

  Call your health plan company to file additional appeals if the decision is not favorable. Many health insurers allow a second and third internal appeal, with different reviewers looking at your claim.

• 6

  File an external appeal if you've exhausted all internal levels without a favorable decision on the claim. Call your health plan company and follow its instructions on how to file the external appeal. This is often the final and binding level of appeal.