How To Appeal an Insurance Claim Denial

It happens to everyone at least once in a lifetime: being notified that an insurance claim has been denied. This insurance claim denial process is upsetting and disturbing but it need not be, if you follow some simple guidelines. Denial of an insurance claim often happens due to several factors: the insurance company denies an authorization, denies the claim because there was a lack of medical necessity, or found that there was incorrect or incomplete information on the claim, etc.

So, when the time comes when you need to appeal an insurance claim denial there are specific steps you need to take:

1. Read your policy booklet, carefully and completely. This insurance booklet is helpful because it will tell you what is covered and what is not, in your plan. This booklet will give you helpful information on copies, deductibles and co-insurance amounts.
2. State the reason for your appeal. If you were unable to contact your insurance company before the service provided was given; this needs to be notated. Perhaps it was an emergency. Or, perhaps a random audit was done and a document you were unaware of stated that you were not covered, due to an error or misunderstanding.
3. Be sure to document any and all conversations and review of your paperwork. It is important to document everything that pertains to your problem. Be sure and put down the date, time, names of people you talked with and write a paragraph or two on what was said and down.
4. Next, be persistent and keep your conversations upbeat and professional. When you talk those on the phone or in writing, be concise about your concerns and be clear about what has happened. Sometimes a quick but concise phone call to your health insurance provider will help speed up the process of the claim and correct the mistake.
5. Keep track of the appeal process. Larger companies often take much longer in processing appeal cases; some as long as several months. In addition, have your physician and an employer sanctioned advocacy group helps with your appeal.
6. Be timely with your appeal process. Do not procrastinate. If your appeal is not filed within a certain time frame, your insurance company could refuse to go further with your appeal.

If all of this doesn’t work, it is important not to give up and to keep trying. The more you continue sending in necessary documentation and evidence, your health care representatives will have to continue their correspondence with you. In order to receive the success you need, you may have to go up higher in the “chain of command.” Seek out the regional director, Vice President or perhaps go as high as the CEO to hear your case. Remember, all you need is for just one person who has the authority to agree to help you.