How to Appeal a Denied Health Insurance Claim – Forbes Advisor

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A health care practitioner typically files a claim with the health insurance company after receiving treatment, services, drugs, or medical items. The insurance company reviews the claim and decides whether your health plan covers the service and how much the provider should be reimbursed. That decision affects how much you pay.

A health insurance company may deny a claim or pay a lot less than you expected. But there is a health insurance claim procedure if you feel your health plan should pay for that care.

What is a health insurance claim?

A health insurance claim is a request for payment made by you or your health care provider to your health insurance company after you have received services, treatment, drugs, or medical items that you believe are covered by your insurance plan. An accepted claim covers the account in whole or in part and reimburses the provider or patient for these costs.

The insurer can deny the claim and refuse to pay or reimburse the services or treatment. The Kaiser Family Foundation estimates that in 2020, 18% of online health insurance claims were denied by health insurance companies in the Affordable Care Act market.

Why should a health insurance claim be denied?

A health insurance company can deny a claim for many reasons, including:

  • The treatment or service is not deemed medically necessary or appropriate.
  • The plan does not cover treatment, service, drugs or goods.
  • The healthcare provider is not in your plan’s network.
  • Your insurer requires a pre-authorization or referral from your primary care physician.
  • The treatment is considered experimental or experimental.
  • Your coverage has expired or you are no longer registered with the insurer.
  • An error in the documentation or data entry prevented the correct processing of the complaint.
  • The complaint was not filed in time.

Claims denied vs. rejected requests

A “denied” claim is actually different from a “rejected” claim. Here’s the difference:

  • A denied claim is one that the insurer deems unpaid. These credits may not be payable due to vital errors or violate the supplier’s contract.
  • A rejected complaint has one or more errors found before the complaint was processed, often because information was missing or incomplete in the complaint form.

Patients or providers are generally notified of a denied claim via a mailed or emailed Explanation of Benefits or Email Remittance Notice. Insurers will usually explain why they denied a claim when they send the denied claim to the claiming party. Most of the rejected requests can be appealed.

Rejected claims must be corrected and resubmitted by you or your doctor. If they are ultimately denied, the rejected requests can most likely be appealed.

What is an expedited appeal?

You can request an expedited appeal if you believe that waiting for a decision on your claim could put your health at risk, for example if you need medication urgently or are currently in hospital.

An expedited appeal is allowed if the timing for the standard appeal process would seriously endanger your life or your ability to regain maximum functionality. In this case, you can simultaneously file an internal appeal and an external review request.

To request an expedited appeal, explain in the appeal request form that you need a faster appeal and state your health reasons in the appeal request letter.

Expedited appeal decisions are usually provided quickly, based on the urgency of the patient’s health condition. In most cases, this decision is made within three calendar days of the initial appeal date.

Two ways to appeal a denial of a health insurance claim

There are two ways to appeal a denial of a health insurance claim: an internal review appeal and an external review appeal.

Internal review

An internal review appeal, also called a “complaints procedure,” is a request to your insurer to review and reconsider its decision to deny coverage for your claim. You have the right to lodge an internal appeal. In this way, you ask your insurer to conduct a fair and thorough review of his decision.

External review

If your insurer continues to deny coverage for a disputed claim, you have the right to appeal for external review. An independent third party does this. It is called “external” because your insurer will no longer have the final decision on whether or not to pay a claim.

Steps relating to challenging a refusal to claim health insurance

Step 1: Find out why the complaint was rejected

If you have received notification from your insurer that your claim has been denied, please read the correspondence carefully, including any explanations of the benefits provided.

Your insurer is legally obliged to inform you in writing and explain why your application was rejected within 15 days if you are seeking prior authorization for treatment, within 30 days for medical services already received, or within 72 hours for urgent care issues .

If the explanation is unsatisfactory or unclear, try contacting your insurer to find out more. Thoroughly document any communication with your insurance company.

Step 2: Ask your doctor for help

Contact your doctor’s office and ask why they believe your insurer denied your claim. It could simply be a problem as the supplier’s office has entered the wrong payment code.

Ask them to verify that the treatment or service provided was medically necessary and that the appropriate medical code has been presented to the insurer. Document everything you learn.

Collect documentation from your provider, including medical records, dates, a copy of the claim form he sent, and possibly a new letter from your doctor requesting that the claim be accepted based on his or her assessment of the situation.

Step 3: Find out how and when to appeal

Review your health insurance policy, which should outline the steps required to appeal, the deadlines to appeal, and how and where to appeal. Call or email the insurer if you don’t have these documents.

Step 4: Write and submit an internal appeal letter

Write a letter of appeal with all the facts, details and reasons necessary to defend your claim. Be as real, concise and respectful as possible. Don’t be threatening, hostile, or offensive in your words or tone.

The National Association of Insurance Commissioners offers an example of an internal appeal letter.

Step 5: Double check with your health insurance company

Review your policy regarding how long you can expect before your insurer will review and issue a decision on your appeal. After this time, or if in doubt, contact your insurance company to check the status of your appeal.

Step 6: File an external review appeal if needed

If your internal review appeal was denied and your request remains unapproved, consider filing an external review appeal. This must be filed within four months of the date you received a final decision or notice from your insurer that your claim has been denied.

Ask your insurer how to officially file an external review.

Step 7: Contact your state

If you’ve run out of appeals with the insurer, contact your insurance department, attorney general’s office, or your state’s consumer affairs office. States can help you with an external complaint denial review.

How long can you appeal against a denial of a complaint?

You have a maximum of six months (180 days) to file an internal appeal after learning that the complaint has been rejected.

If you make a written request for an external review, this must be done within four months of the date you received a notice or a final determination from your insurer that your request was rejected.

How long does it take for a health insurance company to decide on a denied claim?

While the timeline may vary depending on the laws in your state, after filing an appeal you should expect to get an appeal response or decision within:

  • 30 days if your internal appeal is about a service you haven’t received yet
  • 60 days if your internal appeal is for a service you have already received
  • 45 days for standard external reviews
  • 72 hours for expedited external reviews
  • 7 calendar days for experimental or experimental treatments or services requested

What is the law without surprises?

Congress passed the No Surprises Act which went into effect in January 2022.

The legislation sought to reduce the sting of surprise medical bills for group health insurance and individual health insurance plans. The No Surprises Act prohibits:

  • Surprise bills for emergency services from an off-grid provider or facility and without prior authorization
  • Offline cost sharing, including copay and coinsurance, for emergency services and some non-emergency services
  • Off-network bills and balance for supplemental care, including anesthesia, from off-network providers working in an in-network facility

Legislation means that you will not be liable for these types of common charges that lead to surprise medical bills. You still have to pay the normal internal network costs, but the health care provider and the health insurance company must negotiate the payment for the applicable surprise medical bills. They may need to go through an independent dispute resolution process if they can’t reach an agreement, but you as a member won’t be interested.

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