Woman calls health insurance company about denied claim

How to Appeal a Denied Health Insurance Claim

Receiving a denial on your insurance claim, even after you’re feeling better, can be exceptionally frustrating. To help avoid unwanted stress on your finances and your peace of mind, consider the following methods to appeal a denied health insurance claim.

Find Out Why Your Insurance Claim Was Denied

Starts with figuring out why your claim was denied in the first place. 

According to Healthcare.gov, claims can be denied because what you want covered isn’t outlined under your current plan, the benefit was deemed “not medically necessary,” “investigative” or “experimental,” your condition is considered pre-existing, the insurance company suspects you of fraud or you and your insurance company just don’t agree.

When faced with a denied insurance claim, you can fight the decision with an internal appeal, an external review, or both if your claim is denied after the internal appeal process, according to Bankrate writer Sarah Berger.

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Open an Internal Appeal With Your Insurance Provider

Berger reported there is a small window — 180 days — open to an internal appeal, beginning when your insurance sends you its denial. To get the internal appeal process rolling, you’ll need to find out what forms, paperwork or doctor’s statements are required by your insurance provider. 

Whatever paperwork you submit or fill out, Berger recommends making copies for your records. If you’ve already received the claimed treatment or service, you have to hear a response from your carrier within 60 days. It’s 30 days if you’re waiting on the treatment, according to Heathcare.gov.

Launch an External Review on Your Claim

By launching an external review, you’re opting to get the opinion of a third party. If the external review says the denied claim was unjustified, your insurance company must approve your claim.

“Your external review is the last step you can take, and whether the outside party decides to either uphold the insurance company’s 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 company’s policy on external reviews, as you might earn extra time to start the process. But it’s always best to start the process as soon as you can.

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Once you’ve 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 won’t 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 doesn’t have to be the final word on your claim. You have the right to know why your health insurance claim wasn’t approved, and thankfully, with internal appeal and external review processes, you have methods to reverse a denial.

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