How to Appeal a Denied Health Insurance Claim Step-by-Step

Facing a Denied Health Insurance Claim? Here’s What to Do Next

Receiving a denial for a health insurance claim can be incredibly stressful, especially when you’re relying on coverage to make care affordable.

Here’s the good news: A well-prepared appeal can significantly increase your chances of getting the decision reversed. Follow this step-by-step guide to learn how to appeal a denied health insurance claim effectively.

Step 1: Understand the Reason for the Denied Health Insurance Claim

The first step is to understand why your claim was denied. Health insurance providers will usually send an Explanation of Benefits (EOB) or a denial letter explaining the reason for denial, which can include:

• Lack of Medical Necessity: The insurer may believe the treatment wasn’t necessary for your diagnosis.
• Out-of-Network Provider: Coverage may have been denied if the provider or facility wasn’t in-network.
• Coding or Billing Errors: Mistakes in billing codes can result in a denial, even for legitimate claims.

Understanding the exact reason helps you target your appeal and gather the appropriate documentation.

Step 2: Gather the Documentation You Need to Support Your Appeal

Building a strong case requires proper documentation. Here’s what to collect:

• Medical Records: Gather records that demonstrate the medical necessity of the treatment or service.
• Letter from Your Doctor: A detailed letter from your healthcare provider explaining why the treatment is essential can help support your appeal.
• Copy of the Denial Letter or EOB: This will serve as a reference to address specific issues raised by the insurance company.

Organizing these documents strengthens your appeal and helps streamline the process.

Step 3: Contact Your Insurance Provider to Confirm the Appeal Process

Each insurance provider has a unique appeals process, so contact them to verify the steps. Ask about:

• Appeal Deadlines: Insurance appeals often have a strict filing window, usually between 30 to 60 days.
• Submission Format: Some insurers require a specific format for appeals, so confirm whether you need to send physical copies, submit online, or both.
• Documents Needed: Confirm the documentation requirements and whether additional forms are needed.

This step ensures that you don’t miss any critical details that could impact your appeal’s success.

Find a Solace advocate to help with your appeal.

Step 4: Write a Detailed Appeal Letter for the Denied Health Insurance Claim

Your appeal letter is your opportunity to present a strong case for why the insurance company should approve your claim. Here’s how to structure it:

• State the Purpose: Clearly state that you’re appealing the denied claim and identify the claim number, date of service, and provider.
• Explain the Medical Necessity: Outline why the treatment is necessary, referring to your doctor’s recommendations and medical records.
• Attach Supporting Documents: Mention each attached document in the letter, explaining how it supports your claim.

Keep your language professional and straightforward, focusing on facts and medical necessity.

Step 5: Submit Your Appeal and Track Its Progress

For Original Medicare, begin with a redetermination request to the Medicare Administrative Contractor (MAC). Medicare Advantage plans require filing an internal appeal directly with the insurer.

Once your appeal letter and documents are ready, submit your appeal according to the insurer’s instructions. Here’s how to track its progress:

• Submit via Certified Mail or Online: If submitting by mail, use certified mail to confirm receipt. For online submissions, save a copy of any submission confirmations.
• Keep Copies of Everything: Maintain a record of all documents, correspondence, and dates for future reference.
• Follow Up Regularly: If you don’t receive a response within the expected time, call the insurer to check on the status of your appeal.

Tracking your appeal ensures you stay informed and can follow up as needed.

If denied, you can escalate to higher levels, including reviews by a Qualified Independent Contractor (QIC) or hearings with an Administrative Law Judge (ALJ). Independent Review Entities (IREs) handle external reviews for Medicare Advantage plans.

Step 6: Consider External Options if Your Appeal Is Denied

If your initial appeal is denied, you may have additional options:

• Request an External Review: Some cases qualify for an independent review by a third party, which is legally binding for the insurer.
• Contact Your State Insurance Department: If you believe your denial was unfair, your state insurance department may offer resources or a complaint process.
• Seek Support from a Health Insurance Advocate: An advocate experienced in denied insurance claims can provide additional guidance and assist you in further appeals.

Find a Solace advocate to help with Medicare appeals

FAQ: Common Questions About Denied Health Insurance Claims

Why do health insurance claims get denied?

Claims can be denied for reasons like lack of medical necessity, out-of-network providers, and billing errors. Understanding the reason is the first step in appealing.

What should I include in my appeal letter?

Your appeal letter should include a clear explanation of why the treatment is necessary, details of the denial, and supporting documents like medical records.

Can I appeal a denied claim more than once?

Yes, many insurance companies offer multiple levels of appeal. If the first appeal is denied, you can often request an external review.

What if I miss the deadline to appeal?

Missing the deadline can make it difficult to appeal, but some insurers allow extensions under specific circumstances. Contact your insurance provider to discuss your options.

How long does it take for an insurance company to review an appeal?

Appeal reviews can take anywhere from 30 to 60 days, depending on the insurer and the complexity of the case.

Are appeals for Medicare or Medicare Advantage different from private insurance?

Yes, Medicare and Medicare Advantage appeals follow specific processes outlined by federal guidelines. For Original Medicare, appeals start with a redetermination by a Medicare Administrative Contractor (MAC), while Medicare Advantage plans require an internal appeal with your insurer first. And both have additional levels, like external reviews or hearings with an Administrative Law Judge (ALJ), which are not typically available for private insurance.