How to Appeal a Medical Insurance Claim

The time to appeal a medical insurance claim is when the medical service has been denied by the health insurance carrier. The denial reason could be that the medical services are not covered by the plan, that the medical service was not authorized by the insurance carrier before the services were provided, that the services are not covered when provided in this type of setting, or that services are considered experimental for this diagnosis. You can take steps to ensure someone at the insurance carrier takes the time to review the denial and make an informed decision about whether to reprocess the claim for payment.

Things You'll Need

• Denied medical insurance claim (explanation of benefits)
• Health insurance policy
• Miscellaneous documents

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Instructions

Process to Appeal

• 1

  Once you have determined that the claim has denied and have completed follow-up work (phone calls, reviewed written documentation, and so on) for the medical service, you must gather additional information about the denial (reason clarification, health insurance policy, letters, phone conversations) to submit with your appeal.

• 2

  Read over the section of your health insurance policy that provided the definition and / or information about the denied medical services. You would have obtained the location of this information in the health insurance policy based on a phone conversation or from written documentation the health insurance carrier provided. If you do not clearly understand the health insurance policy about the denial, make additional efforts to get clarification from the insurance carrier representative, from physician’s staff members, from the physician, from te hospital billing office, online, and so forth, so you can speak intelligently about the denial error, reconsideration, policy information.

• 3

  Write a letter explaining why you feel the service should be paid or reconsidered for payment. If you had others provide written information or phone conversations about the health insurance carrier’s policy clarification, make copies of those and add them to the letter. Include the explanation of benefits with the letter. When you write the letter, be honest about your interpretation of the medical service, and why you believed the services would be covered even if the policy says they would not be covered. The goal of the appeal is not to prove the health insurance carrier wrong, but to get t to take into consideration the entire circumstances of why the services were needed initially for you, in the way you received.

• 4

  Submit the letter and all of the pertinent documentation to the health insurance carrier’s appeal department address (you would have received this information on the explanation of benefits or medical insurance claim form), with some type of delivery confirmation. The insurer has a set time frame to respond to you, based on when it receives your appeal. It has at least 60 days by law to respond to you or notify you of additional time needed to consider your appeal.