How to Appeal an Insurance Claim

When you know you need medical care and your insurance company denies your claim, don't give up. Be prepared to take action. You have the right to appeal. While each plan may have different procedures to follow, all insurance policies have an appeal process. It's critical to file your appeal, either verbal or written, as soon as your claim is denied. You will have limited time to get the process underway, and doing so will enable you to get the benefits you need. Here's how you can prepare yourself for an appeal if your health insurance claim is denied.

Things You'll Need

• Instructions for filing an internal and external appeal
• Documentation of all conversations
• Letter from the insurer stating the reasons for denial
• Name of person(s) making the denial decision

Show More

Instructions

• 1

  Understand that there are basically two different appeal methods. An internal appeal is directed to the insurance company. An external appeal is made to your state attorney general's office or state insurance department. You have the right to file a complaint with these government agencies at any time if you are not satisfied with the insurer's reason for denial, or the medical information relied on in making the decision to deny your claim.

• 2

  Call your insurance company and request an explanation of why your claim was denied. Get the name of the insurance representative you are speaking with and take your issues to the next-highest level if you don't feel you are receiving the information and service you requite.

• 3

  Request more information from your insurer. Keep in mind that you are entitled to copies of all medical reports, relevant documents, internal rules and any other information that was used in making the decision to deny your claim. Once you receive the documents, review them carefully. Then go over your health plan handbook.

• 4

  Ask your doctor to check the diagnosis and procedure codes that were reported to the insurance company. Often, when a claim is denied, it's because of information the doctor provided to the insurer. The diagnosis made may be a non-covered benefit or associated with a pre-existing medical condition. Ask your doctor for help with your appeal. If you believe the procedure code or diagnosis was inaccurate, discuss your concerns with your doctor and ask that he explain to the insurance company why the medical treatment you need is appropriate and necessary.

• 5

  Send a letter. Be sure to keep your facts in order, such as dates and important supporting documents. Lay out everything you've researched and investigaged in a logical way. Specify in your letter exactly what you think the claim is fair and what you want the insurer to do. Direct your letter to the person who has the power to resolve these issues. Consider sending a copy of the appeal letter to your state Attorney General as well as your state Insurance Department simultaneously. You can find contact information for these agencies on the government websites.