How to File an Appeal With a Health Insurance Company

Health insurance companies routinely deny coverage to patients due to either clinical errors or interpretations of the patient's particular health plan. The company may deem certain tests or procedures as medically unnecessary, or may incorrectly decide that your plan should not cover a certain medication. When you disagree with a health insurance company's decision, it is important to appeal immediately, and to request support from your doctor.

Things You'll Need

• Explanation of benefits
• Copy of your policy
• Copy of your medical records
• Letter from your doctor

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Instructions

• 1

  Review the Explanation of Benefits (EOB) from your insurance company. The EOB outlines the exact charges received from the doctor's office, and explains how much the insurance company will pay for each charge. If the company is denying a charge, the EOB will state why. Reasons can include deeming a charge unnecessary, or a condition "pre-existing," meaning you had it before you were covered by the company.

• 2

  Review your copy of your insurance policy. Insurance companies do make clerical errors, and may claim that your policy does not cover a procedure when it actually does.

• 3

  Call the insurance company immediately if the examination of the EOB and policy reveals that the company has made a clerical error. You can usually correct this error by speaking to a customer service representative. Ask the representative to reprocess the claim correctly. Get a confirmation number and the name of the representative, and make a note of it.

• 4

  Write a letter to the insurance company if the denial is not just a clerical error. Include your full name, address, and policy number. Include the name of the doctor or service provider, and the date of service range. State that you disagree with the denial, and your reasons. Include why the procedure was medically necessary, according to your physician. Attach any relevant copies of your medical records to back up your statements.

• 5

  Mail the letter certified mail so you can get a receipt that shows when the company received the letter.

• 6

  Ask your doctor to write the company a letter. Your doctor can more thoroughly explain why a procedure was medically necessary, or can back up your claims about the dates of your condition, if you are trying to prove it was not pre-existing. Do not wait for the doctor to write the letter before mailing your own.

• 7

  Wait 30 days from the date the company received your letter. You will hear back within those 30 days.