Exactly What to Do and Say to Appeal an Insurance Claim Denial

There are probably a million things you’d rather do than call your insurance company about a bill or coverage issue. But health insurance claims frequently get filed incorrectly, and making sure you’re getting the coverage you were expecting is worth the hassle. To help you navigate an insurance claim appeal — and not pull your hair out in the process — we talked to Adam Fox, deputy director of the Colorado Consumer Health Initiative, and Emily Brown, a patient education content and project manager at Patient Advocate Foundation.

What happens when a health care claim is denied?

You’ll receive a formal letter in the mail stating that you received medical care or treatment that your health insurance company will not cover. It can be frustrating to say the least, especially when you believe (or checked in advance) that your care or medication should have been covered. If your insurer won’t pay, then “the treating health care provider will expect payment from the patient,” says Brown.  

Why would my insurance claim be denied?

For a lot of reasons. A few of the most common explanations: 

• Your health care provider is out-of-network, and you don’t have out-of-network medical benefits. 

• Your treatment required pre-approval, such as a prior authorization for a certain medication, which was not submitted. 

• Your treatment or procedure might not have been considered medically necessary, or was “considered experimental or investigational for your condition,” says Brown. See: Egg freezing.

• Your treatment or procedure may have been coded incorrectly by your medical provider. Meaning the diagnostic code your medical provider put on the claim was not the correct code for your treatment.

• You are no longer enrolled with the insurance company or your coverage has lapsed. 

• There were some “administrative” errors that caused the denial, says Brown. Example: The claim wasn’t filed on time by your medical provider.

In some cases, your medical bill may fall under the No Surprises Act. It means that you can’t receive surprise medical bills for out-of-network services. You may be able to dispute these types of medical bills with your medical provider’s billing department. 

How do I appeal an insurance claim denial?

The process may vary depending on your insurance company. Generally, here are the steps you can follow to appeal a health insurance claim (and what to say), according to our experts: 

Step one: Gather your information 

Call your insurance company and ask them to explain why the claim was denied in detail and request an itemized bill from your medical provider that includes billing codes. If what they coded isn’t what you received, tell them that. Pro-tip: You can Google medical billing codes and don’t forget to track your correspondence. 

SCRIPT: I received a denial for [INSERT MEDICAL SERVICE OR MEDICATION] from you in a letter on [INSERT DATE]. I would like more information on why this claim was denied and my next steps.

Next, call your doctor’s office or medical provider and ask if they plan to file the appeal on your behalf. Even if they don’t, you can still gather helpful information from them, says Brown. That includes medical records detailing test results, and doctor’s notes. If your insurance company claims your treatment was not medically necessary, ask your provider for a Letter of Medical Necessity that proves otherwise. 

SCRIPT: My insurance claim for [INSERT MEDICAL SERVICE OR MEDICATION] that I received on [INSERT DATE] was denied. I’m calling to find out if your office is able to file an appeal on my behalf. If not, I would like to request my medical records for visits/tests from [INSERT DATE OF DOCTOR’S VISITS]. The insurance claim denial says that my medical treatment was not medically necessary. Can you please provide a Letter of Medical Necessity to prove that it was? 

Finally, look over your health insurance policy. It should be able to tell you when and how to submit your appeal. You can also ask about this when you first call your insurance company. Typically, you have up to six months to file the appeal from when you receive the initial denial letter.

Step two: Send a formal letter to your insurance company

Once you have all the information above, you’ll send a formal letter to your insurer (you’ll either mail this in or upload it on your insurance company’s website, depending on how they request appeals to be submitted). The letter should make your case for why your medical care should have been covered, why you needed the medical service or medication, and why you believe your insurance policy covers it. “Describe your medical condition and the impact it has had on your life,” says Brown. Here’s a sample appeal letter to get you started: 

[DATE]

[INSURANCE COMPANY NAME]

APPEALS AND GRIEVANCES DEPARTMENT

[ADDRESS OF HEALTH PLAN’S APPEAL DEPARTMENT] 

Re: [YOUR/INSURED MEMBER’S NAME]

[MEMBER ID]

[REFERENCE NUMBER ON EXPLANATION OF BENEFITS]

[DATE OF BIRTH]

To Whom It May Concern:

I am writing to appeal the [HEALTH PLAN NAME] decision to deny [INSERT MEDICAL SERVICE OR MEDICATION] coverage for [YOUR NAME OR MEMBER’S NAME IF OTHER THAN YOURSELF].

It is my understanding that [HEALTH PLAN NAME] is denying coverage because "[INSERT REASON FROM DENIAL LETTER]." I have reviewed my policy and believe [NAME OF MEDICAL SERVICE OR MEDICATION] should be covered. I wish to file an appeal concerning INSURANCE COMPANY’S NAME]’s denial of a claim for [NAME OF MEDICAL SERVICE OR MEDICATION].

The [NAME OF MEDICAL PROVIDER OFFICE] team has recommended that [NAME OF MEDICAL SERVICE OR MEDICATION] is medically necessary. [NAME OF MEDICAL SERVICE OR MEDICATION] is a covered service, as stated as a covered benefit in your member of handbook: [QUOTE MEMBER HANDBOOK STATING THAT TREATMENT IS COVERED]. 

I was diagnosed with [NAME OF HEALTH CONDITION/DIAGNOSIS] on [DATE]. Unfortunately, it has significantly impacted my daily life as evidenced by [INSERT SYMPTOMS]. [NAME OF MEDICAL SERVICE OR MEDICATION] was medically necessary to treat [NAME OF HEALTH CONDITION/DIAGNOSIS] because [INSERT HOW MEDICAL SERVICE OR MEDICATION HELPED YOU]. If I had not received [NAME OF MEDICAL SERVICE OR MEDICATION], [REASON/CONSEQUENCE OF NOT RECEIVING TREATMENT]. 

I have attached [LIST ATTACHED DOCUMENTATION] to illustrate that [NAME OF MEDICAL SERVICE OR MEDICATION] is a medically necessary and covered benefit. 

[IF MEDICAL SERVICE WAS OUT OF NETWORK: Establish that there are no comparable services offered within the network.] 

Please review the provided documents and reconsider allowing coverage of [NAME OF MEDICAL SERVICE OR MEDICATION], as this treatment was necessary to my health.

If you need additional information, I can be reached at [PHONE NUMBER AND EMAIL ADDRESS]. I look forward to receiving your response as soon as possible.

Sincerely,

[INSERT NAME]

Brown says you can go one step further and provide published journal articles or data that “shows the benefits and success of the prescribed treatment/service” in the letter. (PubMed is a good place to start). Also, provide both your and your doctor’s contact info. 

Step three: Wait and follow-up

Depending on your insurance company, they typically have to respond to your letter within 72 hours of receiving it for an expedited appeal, when “the standard appeal process would jeopardize your life or potentially cause you serious pain or harm,” says Brown. They have 30 days for non-urgent medical services that you haven’t yet received (in the case that they deny a prior-authorization request), and 60 days for medical services you’ve already received. You can always call them and check on the status in the meantime. 

SCRIPT: Hi, I filed an appeal on [INSERT DATE]. Can you please tell me if it has been received and is in the correct department for processing? I would also like to know how long a decision may take.

Every time you make a phone call, keep track of your correspondence. Once your appeal is processed, your insurer should provide a written response within the allotted time.  

What happens if my appeal is denied?

“The first appeal is not necessarily the last opportunity that you have by any means,” Fox says. You have a legal right to a certain number of appeals. Call your health plan to find out how many you have available. You may be able to request an external appeal, says Fox. That’s where a third party will intervene and review your request (though there may be a fee). 

SCRIPT: Hi, I have received a denial for my appeal submitted on [INSERT DATE]. Are there any more appeals available to me?

If you’ve gone through every option here and still have a medical bill to pay, however much, you can always try to negotiate your bill down. Call the medical provider’s billing department (yes, another phone call), and ask them how you can reduce your financial responsibility. Keep in mind that they get these calls all the time, and are often willing to help. You can also ask about financial aid, medical forgiveness options, or payment plans to ease the burden. 

theSkimm

Fighting with your insurance company is frustrating. But seeing the process through can help you save big and potentially avoid medical debt. If you feel like you’re getting lost in the process, a health insurance appeal correspondence tracker may help.