How to Appeal a Denied Health Insurance Claim

It can be frustrating to go to the doctor when you have health insurance only to have the health insurance company deny the claim afterward.  Initial denial does not mean that a denied health insurance claim cannot be reversed.  Sometimes it can simply be a clerical error, or the problem may be that the claim was not deemed medically necessary.  It is more difficult to get that kind of decision reversed, but it is still possible.

Make the Call

The first thing to do after getting a denied health insurance claim is to call the insurance company and ask a representative to explain the justification for the denial.  It may be as simple as the way the claim was processed or that there is missing or incorrect information, such as an incorrect medical billing code.  If this is the case an appeal will probably not be necessary, just a re-submission with correct information.  If the problem is more complex, ask how to begin the appeals process.

The Appeals Process

When you have a denied health insurance claim it is important to find out what will be required to file an appeal.  Procedures vary between insurance companies but are usually similar.  Ask the representative what needs to be done in order to get the process started.  Take notes and get the representative’s name, employee ID, and the time and date of the call, so that there is a record of what has been done.  Also be sure to get the mailing address for where to send the appeal.  Often the appeals address is different from the claims address.

The Letter of Appeal

When writing a letter of appeal you have to include the type of procedure or service, any relevant details, the date of service, the claim number, the insurance member ID number, the group policy, the provider and the amount due.  Discuss the reason that the denied health insurance claim should be appealed clearly and concisely.  Also be sure to include any supporting documentation such as medical records or doctor’s referrals. It is very helpful to obtain a note from your doctor stating that they considered the procedure or visit medically necessary.

Mailing the Letter

As with any important document it is vital to use certified mail with a return receipt. This is particularly true in the appeals process for a denied health insurance claim.  Using certified or insured mail provides a paper trail verifying when the letter was mailed and who received it, because they must sign for the mail. Insurers frequently “lose” correspondence, so if follow-up calls are necessary the name on the return receipt can be referenced.  In addition, if there is any reason to pursue legal action regarding the claim proof of the mailing will be necessary as well.

Getting a denied health insurance claim can cause panic; however, with a little due diligence the situation can often be corrected.  A billing code error, a clerical error or a submission error are often the source of the problem.  Even when the issue is more complicated it may still be a simple process to get the claim resubmitted to the health insurance company for a review.  Persistence and attention to detail will serve you well when fighting a denied health insurance claim.