How to Appeal a Medical Insurance Denial for Emergency Room Treatment

Insurance companies may deny claims for emergency care based on a variety of reasons, including using an out-of-network hospital, receiving emergency services not covered by the plan and accessing an emergency room for what is deemed by the insurance provider to be a non-emergency. If you feel that your claim has been wrongly denied, you have the right to appeal the denial.

Things You'll Need

• Medical records for ER visit and other supporting documentation
• Appeal forms from insurance company

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Instructions

• 1

  Contact the hospital that provided emergency care upon notice of denial, stating that you will be appealing the insurance claim denial. If you do not inform the hospital of this, the hospital is likely to assume that you are refusing to pay the bill and may forward your bill to a collection agency.

• 2

  Contact your insurance provider to obtain an explanation of benefits. This will state the exact reason for the denial.

• 3

  Obtain directions from your insurance provider for appealing a denied claim and submit all requested forms and supporting documentation showing that the claim was wrongly denied. If any time restraints exist for filing an appeal, make sure that you submit the forms prior to the deadline. Send all forms via certified mail in order to have proof that the insurance company received the appeal paperwork. If a second appeal is allowed upon denial of the original appeal, submit the second appeal. Continue this process until a favorable decision is reached or your number of appeals are exhausted. Continue to step four if the claim denial is upheld through all levels of appeal offered by the insurance company.

• 4

  Contact your state's external review program for insurance providers and file an appeal for your denied claim through the external review program. A third party will review the appeal and decide whether the claim was wrongly denied or not. The Kaiser Family Foundation has links to each state's external review program on their website. (See References 1)