How To Appeal Denied Health Insurance Claims
I hope you all had a nice weekend.
Did we miss anything? Do you have a story/tip you could share with us?
Hi Jen: Thanks for posting this article! A little bit of knowledge and a lot of organization can make all the difference in a successful insurance appeal. I would chime in that keeping detailed notes of phone calls , following up in writing always, and making sure that you meet every deadline laid out in your policy can make or break the claim. As a former in-the-trenches attorney for insurance carriers and as a current advocate who handles insurance appeals and grievances, the paper trail is critical.
For private insurance, make sure to ask for a full copy of the policy. It should set forth the rights and responsibilities of an insured. If you have questions about why a claim was denied, you may wish to request a complete copy of the claim diary and notes from the adjusters who handled your file. This may give a lot of insight into the denial.
Also, your state’s laws may have additional protections or requirements they have if you want to pursue the claim. For example, in Florida, our laws have notice requirements before we file lawsuits for insurer violations.
Finally, for caregivers who are handling insurance claims and appeals for someone else, it is crucial that you have the proper paperwork to speak on behalf of the insured person .
She is applying for Medicare now since she will be 65 in February.
S In The External Review Process
1. Internal Appeals: Complete internal appeals with your insurance carrier. Cases are only eligible for an external review once the internal appeals process with the insurer has been exhausted. Check with your insurance carrier for details on levels of internal appeals and for clarification if these have been exhausted if you are unsure.
2. Initial Paperwork: You have four months from the date you receive a denial notice to request an external review. Your external review can be completed through the external review secure portal, which will allow you to check on the status of the external review at any time, and which will send you an email notice of each event occurring as the external review progresses, as well as an emailed determination immediately when the external review is complete.
If you do not wish to type information into the portal, the forms for an external review are available for printing below. Your external review will be processed through the portal once the Department of Insurance receives your documents by mail or fax. An external review specialist from the Department will contact you to determine if you would rather receive the final external review determination by mail or receive ongoing updates from the portal to your email. Instructions for submitting the external review request on paper are included on the printable form.
To obtain an expedited review
PO Box 95087
Pay Attention To The Timeline
Its easy to call the insurance company once and then forget about it, but you have to follow up. Set up a system to remind yourself to follow through. If a customer service agent tells you he is going to resubmit your claim and it will take about a week to be processed, make a note in your calendar to call back in a week to check on the status. The company is more likely to move your claim through the pipeline if you apply a little gentle pressure.
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How To Appeal A Denied Health Insurance Claim
You can often fight back, whether you’re on Medicare, you’re insured through an employer, or you buy your own health insurance
Did you recently get a letter from your insurer denying coverage for a test, drug, or other healthcare treatment?
If so, youre hardly alone, whether you get insurance through your employer, buy it on your own, or are on Medicare. One recent study, for example, found that 17 percent of claims from people insured through an Affordable Care Act marketplace plan were denied in 2018. Another study, of people covered through a large Medicare Advantage insurer, found that nearly a third had at least one claim denied over a one-year period. Those denials can leave you on the hook for big medical bills..
But you dont have to take it lying down, says Caitlin Donovan, a health policy expert at the Patient Advocate Foundation. She notes that there are steps you can take to fight those denials, regardless of where you get your health insurance. If you sought preauthorization for a healthcare service and were denied, you can appeal that decision, too.
First off, mistakes can happen at multiple points in the claim filing or preauthorization process, so phone your insurer to make sure the decision was not made in error. If it was not, ask to speak to the reviewer behind the decision and request an explanation. Keep notes, because youll need this information in writing later, Donovan says.
Appealing A Health Insurance Denial
Reading time: 4 minutes
Its crucial to ensure you and your loved ones are safe and healthy during the Coronavirus/Covid-19 pandemic, especially as more states lift stay-at-home orders and businesses gradually reopen. You may be following recommended precautions to protect yourself from illness, including washing your hands frequently, social distancing and wearing a mask when you leave home.
At the same time, you may be concerned about how you would afford the cost of treatment should you or a loved one get sick. Dealing with an illness or injury is difficult enough without the financial burden of paying for your care, especially if your health insurance claim is rejected. An insurance company may deny payment for medical care for a variety of reasons, including a determination that the treatment your doctor has recommended isnt medically necessary.
But you dont have to accept a denial as the final answer. If your insurance claim is rejected, you can file an appeal or several, if necessary to persuade your insurance company to cover the treatment.
The first step, though, is to try to avoid a denial in the first place by understanding your health insurance plan. Review the limits and guidelines of your particular policy and follow them to the best of your ability. If you are required to secure a referral from your primary care provider before seeing a specialist, do so to avoid a denial.
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Why Was My Claim Denied
The first thing to do is to figure out why your claim was denied.
The General Insurance Code of Practice requires insurers to provide reasons for rejecting your claim.
Typically, you’ll receive a letter from your fund detailing the reasons for their decision.
Read the letter carefully to find out why your claim was denied.
Write A Concise Appeal Letter
When you write a health insurance appeal letter, be sure to include your address, name, insurance identification number, date of birth for the person whose claim was denied, date the services were provided and the health insurance claim number, Goencz says.
“The first sentence should state that you are appealing the claim denial, and the body of the letter should explain why the medical bills should be paid,” Goencz says. “Put in a closing sentence demanding payment, and include supporting documentation.”
Include details on what you’re appealing and why you feel your claim should be paid.
“You need to appeal based on the reason that something has been denied. So, if something has been denied because it’s not a covered service, then saying that something is medically necessary doesn’t count,” Jolley says.
Save emotional rants for understanding friends. Stick to the facts.
” don’t want to know about your grief and how sick you’ve been,” Stephenson says.
Send by certified mail to get notification that the packet was received, she adds.
Here’s what you can submit:
- Your letter of medical necessity
- A copy of your denial letter
- Other supporting documents by the deadline
Track everything so you have proof of when you submitted your appeal. That could include a fax number or post office tracking number.
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Tips For Appealing A Denied Health Insurance Claim
1) Understand Why Your Claim Was Denied: This may seem like an obvious first step, but its important to know the specific reason your claim was denied.
2) Start with Simple Fixes: Oftentimes, a denied health insurance claim is due to something minor that can be easily fixed, usually an administrative issue. Make sure youve taken care of all of the little things before appealing a denied health insurance claim.
3) Meticulous Evidence Gathering: It is important to have as much evidence as possible on hand, just in case you need it down the road when appealing denied health insurance claims. Keep all of your paperwork organized so that you can easily access any information if needed.
4) Paperwork Is Critical: If a health insurance claim is denied because they didnt receive the proper paperwork, youll need to resubmit your request. Make sure that any relevant information is submitted with the appropriate forms when appealing a denied health insurance claim.
5) Organization Will Make Everything Easier: It can be easy to get overwhelmed by this process and lose track of things if theyre not organized properly. Make a list of all deadlines for submitting forms and evidence, and keep all of your paperwork in one place.
6) Be Punctual: Each step of the appeal process will have its own set of deadlines. Make sure you know what they are and when theyre due so that you dont miss any important steps when appealing your denied health insurance claim.
Launch An External Review On Your Claim
Your external review is the last step you can take, and whether the outside party decides to either uphold the insurance companys denial of your claim or reverse it, your insurer must accept it, writes Berger.
Once you receive notice from your insurance company that your claim has been denied, you have only 60 days to seek intervention from an external review, according to Healthcare.gov. Make sure to check your insurance companys policy on external reviews, as you might earn extra time to start the process. But its always best to start the process as soon as you can.
Once youve filed the paperwork necessary for an external review, a decision must be made within 60 days. A fee of approximately $25 may be assessed if your insurance company uses a state external review process or an independent review company or organization to fulfill the review.
Healthcare.gov writes that you wont pay anything if your insurance company enlists the U.S. Department of Health and Human Services protocol to facilitate the review.
Your state Department of Insurance and Consumer Assistance Program are helpful resources when appealing a denied claim.
A denial from your insurance company doesnt have to be the final word on your claim. You have the right to know why your health insurance claim wasnt approved, and thankfully, with internal appeal and external review processes, you have methods to reverse a denial.
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Contact Norton Health Law Today
If you have exhausted all levels of the administrative appeals process without a satisfactory result, our team at Norton Health Law can help you fight your insurers decision. We are committed to improving the quality and length of our clients lives by advocating for their healthcare rights.
Give us a call at 216-4020 to request a free initial consultation to discuss your case and how we can assist you.
Schedule a Free Consultation
If You Can’t Resolve Your Problem Directly With The Health Plan
If all the internal and external appeals are exhausted, and the claim is still denied, ask the health care provider if the cost of the bill can be reduced. Many providers are willing to reduce bills to get paid faster. If all else fail, you might have to take your appeal to a higher level.
It helps to know who regulates a health plan if you have a problem that you cant resolve directly with them. You can talk to the government group that regulates the health plan to find out if they can offer more information or extra help.
Private group plans purchased from insurance carriers by employers as a benefit for employees are usually overseen by the insurance commissioner or department of insurance in each state. You can find your states insurance department by contacting the National Association of Insurance Commissioners.
Self-funded plans are health plans that employers or unions create just for their employees and their families. They are overseen by the US Department of Labors Employee Benefits Security Administration. Because employers often contract with insurance companies to administer these plans, its difficult to tell if a work-based plan is self-insured. You will have to ask your employer if your health plan is self-insured.
Individual plans sold through the health insurance marketplaces are regulated by a marketplace board in every state. This state board oversees the function of the marketplace and the plans sold within it. www.healthcare.gov
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What Your Appeal Letter Should Include
A health insurance claim denial can frustrate you to tears. Keep the emotion out of it. A simple appeal letter that gets straight to the point is the best approach. Your appeal letter should be “matter of fact” in tone. Include any information your insurance company tells you is needed.
Your appeal letter should include these things:
Appealing A Decision Made By Your Health Insurer
If you disagree with a decision your health insurer made regarding your health care claim, you have the right to appeal the decision. There are two levels of appeal an internal appeal with your health insurer and an external review with the Department of Insurance and Financial Services .
An external review process should only be initiated if:
The covered person has exhausted the health carriers internal grievance process.
The health carrier fails to provide a determination within the timeframe dictated by law.
- Internal Appeal Process
Michigan law provides you the right to file an internal appeal if you disagree with your health insurers claim determination, also known as an adverse determination.
An adverse determination means that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been denied, reduced, or terminated. Failure to respond in a timely manner to a request for a claim determination is also an adverse determination.
When you receive an adverse determination notice, you must notify your health insurer in writing that you want to appeal their decision.
The adverse determination notice will provide the timeframe in which you are required to submit your written appeal. Once you file an appeal, the health insurer is required to complete the internal grievance process within:
- 30 calendar days for a pre-service denial.
- 60 calendar days for a post-service denial.
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What Are My Rights In An External Review
Insurance companies in all states must offer an external review process that meets the federal consumer protection standards.
State: Your state may have an external review process that meets or goes beyond these standards. If so, insurance companies in your state will follow your states external review processes. Youll get all the protections outlined in that process.
Federal: If your state doesnt have an external review process that meets the minimum consumer protection standards, the federal governments Department of Health and Human Services will oversee an external review process for health insurance companies in your state.
Depending on your plan and where you live, the following may apply to you:
- In states where the federal government oversees the process, insurance companies may choose to participate in an HHS-administered process or contract with independent review organizations.
- If your plan doesnt participate in a state or HHS-Administered Federal External Review Process, your health plan must contract with an independent review organization.
Appealing Health Plan Decisions
If your health insurer refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party.
You can ask that your insurance company reconsider its decision. Insurers have to tell you why theyve denied your claim or ended your coverage. And they must let you know how you can dispute their decisions.
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Sample : Insurance Provider Form
Since the insurance providers are the organizations who deny the medical claims that you submit, they have no choice but to have a standardized process put in place.
Thus, many of them allow for electronic submissionbut only if you use the form that they provide.
The form provided above is just the first page in the appeal form provided by Medical Mutual.
It has everything going for it. Its
Using interactive forms
It even provides extra information about the insurance organizations timely filing limit.
Maybe this is the golden sample. We can throw every other sample that I went over earlier in this blog post, right? Wrong.
You see, on a small scale sending filling out the electronic appeal letterforms that exist on insurance providers websites is attainable.
However, not every patient that comes through your doors seeking help uses Medical Mutual. Id wager to bet that if ten of your patients walked through your door all at once, less than half of them would use the same insurance.
In other words, you and your staff cant keep up with all of the different electronic appeal forms for every denial you receivefrom all of the different insurance carriers your patients use.
Going this route is an option, but its not perfect.
If My Health Insurance Company Participates In The Hhs
- Visit externalappeal.cms.gov. Youll be able to file a request using a secure website. For claimants who are able to do so, the portal is the preferred method of submission for review requests.
- Mail an external review request form to: MAXIMUS Federal Services 3750 Monroe Avenue, Suite 705 Pittsford, NY 14534
- Submit a request via email: is
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