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How to Appeal a Denied Health Claim

Updated: Aug 18, 2023

Managing medical expenses and denied insurance claims can be overwhelming – especially with chronic health conditions. The likelihood of you receiving a denied claim has increased. According to a Kaiser Family Foundation study, one in 500 denied claims are appealed. Don't let denials stand in the way of the vital care you need. Learn how to successfully appeal and get the coverage you deserve with these steps.

1. Understand the Denial Reason: Before you begin, know why your claim was denied. Look at the explanation of benefits or denial letter from your insurer. It could be due to incomplete information, lack of medical necessity, pre-authorization issues, or non-covered services. This understanding will be vital when building your appeal.

2. Review Your Insurance Policy: Dive into the fine print of your policy to grasp your coverage, exclusions, and limitations. Familiarize yourself with the terms and conditions, including any requirements for pre-authorization, referrals, or specific documentation. This knowledge will determine if your appeal has merit and if you have grounds to appeal.

3. Gather Supporting Documentation: Collect all relevant medical records, bills, and correspondence related to your denied claim. This includes physician notes, diagnostic reports, treatment plans, and prescriptions plus any other evidence that supports the medical necessity of the service or treatment. These documents will form the foundation of your appeal and strengthen your case.

4. Contact Your Healthcare Provider: Get in touch with the billing department where you received the services. Discuss the denial, make them aware of your intention to appeal, and gain their support. They can provide information, clear up misunderstandings, and supply additional supporting documents.

5. Follow the Insurance Company's Appeal Process: Insurance companies have specific procedures for appeals with no one insurance company having the same steps as another. Follow them closely and remain organized. Pay close attention to the deadline for submission to avoid forfeiting your right to appeal. For example, Blue Cross Blue Shield has a 365 day timely filing limit. However, you'll want to act on submitting your appeal as soon as you receive the denial while it is fresh in your mind. Explain in detail why you believe the denial is incorrect, referring to your gathered documentation for each point referenced.

6. Seek Assistance from Your Healthcare Provider: Request a letter of medical necessity from your doctor as well as supporting documentation. A well-crafted letter that addresses the specific denial reasons and provides persuasive arguments supporting the review of the denial can significantly bolster your case.

7. Understand the Internal Appeals Process: If your initial appeal is denied, most insurance companies offer an internal appeals process. This involves escalating your appeal to a higher level within the insurance company. Be prepared to provide additional documentation or any new evidence that supports your case. Follow all instructions provided by the insurance company and maintain copies of all correspondence for your records. Remember to submit requests before your insurance's deadline.

8. Seek External Assistance When Needed: If your internal appeal is also denied, or if your insurance provider does not offer an internal appeals process, you may want to take the next step and seek external assistance. Contact your state's insurance department or regulatory agency to understand the options available to you. They can provide guidance, mediation services or help you file a complaint against your insurer if warranted.

9. Facilitate an Independent Review: In some cases, you have the option to request an independent review. Independent review organizations (IROs) are impartial entities that assess the denial and make binding decisions. The IRO will review your case based on medical evidence and applicable laws. Check your insurance policy or contact your state insurance department to determine if an independent review is available to you.

10. Legal Remedies: If all else fails, and your supporting documentation firmly shows your claim was wrongfully denied by your insurance company, consult with an attorney specializing in healthcare or insurance law. Legal remedies should be a last resort due to the associated costs and time involved. An attorney can evaluate your case, advise you on the best course of action, and represent your interests in court, if necessary.

Appealing a denied health claim requires patience, persistence, and a thorough understanding of the process. By following these steps, you can navigate the appeals process with confidence and increase your chances of overturning the denial. Remember to stay organized, gather supporting documentation, and leverage the assistance of your healthcare provider throughout the appeals process. Your commitment to advocating for your rights as a patient can lead to a successful resolution of your denied health claim.

Need more help with resolving a medical or dental bill issue? Contact your area's local patient advocate or reach out to MBCR today!

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