How to Appeal a Health Insurance Claim

While there are many types of health insurance plans, the process for filing a claim is largely the same. You may find more comprehensive coverage through a long term plan, but you can file claims for most unforeseen illnesses or injuries with short term health insurance companies. The easiest way to file a claim is to simply have your healthcare provider submit your claim directly, but you can send the paperwork in yourself. This is most commonly required when your healthcare provider is not in the same network as your insurance provider.

To file yourself, you’ll need itemized receipts from your doctor that you can attach to your claim form. You’ll also want to make copies of all forms in case something gets lost in the claims process. It’s also a good idea to contact your health insurance provider before you send your claim to ensure you have everything in order. Receiving a denial letter after submitting a claim is certainly a frustrating setback, but you have options for a better outcome.

Why are claims denied?

There are a variety of reasons that a claim can be rejected or denied, and there is a distinction. A claim is considered rejected when there are errors in the paperwork, and sometimes just fixing these errors can be enough to see the claim approved. However, for other reasons, approximately 200 million claims are denied each year. Your first step to starting and appeal is to find out why your claim was denied.

Common reasons for denials include filed procedures not being covered on your insurance plan, lack of pre-authorization for treatment, using an out of network provider, filing outside of time limits, or procedures not being deemed as medically necessary. Regardless of the reason behind a denial, many are successfully appealed, and you have options when fighting for your rights.

Filing an appeal letter

Once you understand why your claim was denied, you’ll need to start working on your initial appeal letter. The goal is to communicate your information as efficiently as possible to move your case along quickly. Keeping the letter as to-the-point as possible is generally the best approach.

Your letter should include an opening statement that identifies your claim number and describes your health services or treatments as well as the reasoning for the denial. You will then need to explain your medical history and why you believe the procedures should have been covered and/or were medically necessary. A supplementary letter from your doctor can help support this. You’ll also need to include any other supporting information you can, such as documents that identify your procedures as part of a recognized treatment plan.

Seeking outside help

It’s important to keep in mind that you don’t have to fight a claim denial alone. Most hospitals have social workers who will be glad to review your case and help you take advantage of all the benefits available to you. They may also be able to link you to charity care to help pay your expenses if a successful appeal looks impossible. You shouldn’t give up on an appeal after a single letter, though. Sometimes it can take a second appeal, or even more, before an insurance company pays out.

If you aren’t having luck with the internal review process, then you can request an external review to be carried out by an arbitrator. The arbitrator will then look over the claim and the reasoning for the denial, and they may uphold or overturn the insurance provider’s decision.

In more difficult cases, it can be a good idea to hire an experienced attorney like Howard Fensterman. Healthcare attorneys have likely seen cases like yours before, and they’ll know if your rights are being violated. If necessary, they can help you take your case to court if you’ve been denied a deserved payout.

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