Did your insurance deny your health care claim? How to appeal.

Easy steps to challenge a health care claim denial. It's worth it.

Whether you have Medicare or private insurance, learn how to challenge health insurance claim denials with this easy guide.

Health care

Tips & Guides


Updated

You can appeal health insurance claim denials. Follow these simple steps.

It’s a terrible feeling. You open a letter from your health insurance to see coverage for some of your recent care was denied. Now you have to deal with a medical bill that is far bigger than you were expecting.

When you go to the doctor or get lab work, scans or images, your insurance provider should cover most of that cost, depending on your plan. However sometimes, insurance companies deny claims, which means you need to pay for it yourself. Claim denials are happening more often with the use of technology that limits individual claim reviews by doctors employed by insurers. In 2020, almost 1 in 5 insurance claims were denied. Even though patients have the right to challenge those denials, less than one percent do. But insurance companies do make mistakes. That’s why it makes sense to challenge health insurance claim denials.

Get started - How to spot an incorrect health insurance claim denial

Examples of health insurance claim denials you should appeal.
  1. Your insurance plan wrongly decided the service is no longer medically necessary for your care.
  2. Your insurance wrongly denied a claim for a service that should be included in your coverage.
  3. Your doctor or hospital incorrectly filed the claim. (Provider wrote the wrong billing code, didn’t provide all the information the plan needed or other errors, etc.)
First steps to challenge a denial of your health insurance coverage

Follow these steps to reverse a claim denial. It’s important to challenge the decision of your insurance company to deny a claim. If you believe your health plan should pay for your care, start with these steps.

  1. Review the claim denial letter from your health plan and compare it to the bill you received. Write down any questions you have.
  2. If you have questions, contact your healthcare provider (doctor or hospital). Make sure that they have billed you for the correct amount, and that the bill is not an error.
  3. Use this handy tool to write a letter to your insurer to request the information they used in making the decision to deny your claim. The insurer should respond within 30 days. After you receive the claim denial notes and information from your insurer, you’ll have a better sense of how you to make the best case when you file an appeal with your insurer.
  4. File an “appeal”. Use the number on the back of your insurance card or your insurance website to understand what you need to do to file an appeal (“Appeal” is the term used for challenging the decision by your insurance company to deny paying for a health insurance claim.)

Remember that many people don’t challenge a claim denial, but when they do, they win about 50% of the time.

To be successful, you must gather the documents you need and follow the appeal steps for your type of insurance.

Challenging health insurance claim denials.

The information you need to challenge a claim denial

When challenging a claim denial, gather these documents. Keep the originals and only submit copies.

  • Your Explanation of Benefits (EOB) form details which costs are covered by insurance and which are denied. (Only those with private insurance have EOB’s)
  • For Medicare beneficiaries, your Medicare Summary Notice (MSN) form details which costs are covered by Medicare and which are denied. 
  • Your letter requesting an appeal. 
  • Letters or forms you have to sign for your doctor or insurance which relate to the appealed claim. 
  • Notes on any conversations you have with your insurer and providers. Get the name of the person, and write down the time, date and phone number.
How to challenge Medicare health claim denials

For those insured through Medicare:

Step 1: Find your Medicare Summary Notice (MSN). An MSN is sent every 3 months from your insurer. Or look it up on your online Medicare portal.

Step 2: Check the date of the MSN. You have 120 days after receiving your MSN to file your appeal. If you missed that deadline, when you file your appeal be sure to explain why you are late. You can login to see your claims at any time on your online Medicare portal

Step 3: Look at the MSN to see which claims were denied. This is considered the “initial determination.” Make a copy of the MSN and circle the denied claims that you want to appeal. 

Step 4: Fill out a Redetermination Request Form. If you can’t print out this form, you can write a letter that includes all of this information. Try to include as much information as possible but don’t worry if you don’t have all of the information. 

Step 5: Find the address for your insurer listed on your MSN and mail the Form or your letter. 

You should know within 60 days of sending in this appeal. If your appeal to the insurance company is unsuccessful, you have 4 other levels of appeal.  The next steps can be found here.

How to challenge health claim denials, if you have private insurance

For those with private insurance: 

Start with an “internal appeal.” The insurance company will review decision to deny your claim based on the information you submit. Here’s how:

Steps to file an internal appeal:

Step 1: Find your Explanation of Benefits (EOB), which details the claims and the amounts you owe. It might come by mail, or you can access it through your online account with your insurance company. 

  • Identify any denied claims on your EOB that you want to appeal. 
  • Check the date of the EOB. You must appeal within 6 months of the claim denial.

Step 2: If you haven’t already gotten information from your insurer to find out why your claim was denied, use this tool to draft a letter to request that information.

Step 3: Write a letter to your insurer explaining which claim you would like to appeal and why. Here is an example letter. Be sure to include your name, address, phone number, plan number, and which denied claims you are appealing. Include a copy of the EOB. 

Step 3: If you want, you can also include other information which you believe supports your appeal. You might want to include a letter from your doctor explaining why you needed the treatment. Or send copies of the parts of your medical record that show why you need the treatment or service. Here’s how to get a free copy of your medical record.

You should know whether you won your appeal within 30 days of sending it in. If your internal appeal is unsuccessful, you can request an “external appeal”.

How to file for an “external appeal” for a denied health claim

If you don’t win the internal appeal, you can file an external appeal. In external appeals, a third party is the final authority, not the insurance company.

Your Explanation of Benefits will have the contact information for the organization that will handle your external review. You must file an appeal for external review within 4 months of your denied internal appeal (or explain your reasoning for your inability to file on time). Note that you will have to pay $25 for your external review, and the decision from the external reviewer is final.

Health insurance words you should know (a list of definitions)

Claim: A request for payment that you or your health care provider sends your health insurer when you get health care items or services 

MSN: Medicare Summary Notice, document with all your claims, and their payment status, for the last 3 months

Redetermination request form: the form you fill out to officially ask for the denial to be reconsidered

Explanation of Benefits (EOB): A document from your insurer that explains what treatment and services are covered and what claims are denied. It also contains the information on how to file for an appeal of any denied claims. 

Coinsurance: An amount you must pay out-of-pocket as a percentage of the price of the service. It is in the form of a percentage (such as, 10%). For example, if the cost of a service is $600 and you have 10% coinsurance, you are responsible for paying $60 as your coinsurance.

Copay: A fixed cost you must pay out-of-pocket for a specific service, like a prescription drug or a primary care appointment. For example, you may have to pay $20 for every doctor visit, or $20 for a certain type of medication every time you refill that prescription. you will pay $20.

Deductible: The amount of money you must pay out-of-pocket at the beginning of your insurance plan year. Check with your insurance company to understand when your insurance plan year starts and ends. After reaching the deductible, you will typically pay less for services. 

For example, at the beginning of the plan year, if your first medical bill is $6000, and you have a $2,000 deductible, you will owe $2,000 and insurance will cover the remaining $4,000. Or if your first medical bill is $500, you will pay the full $500 for that service. And you will continue to pay all of the cost of any future care until you have paid $,2000 (your deductible amount). Your insurance will then take over paying the bills. Remember, you will also have to pay any copay or coinsurance.

We are collecting examples of problems people experience with medical billing and insurance coverage. Please share your billing problems and claim denials with us. Use this link Medical Bills and Strange Fees Story Submission.

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