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

1. Your doctor or hospital incorrectly filed the claim. If your insurance denial code reason is tagged as “administrative,” it likely means that your provider didn’t provide the correct information the plan needed to approve the coverage, or other clerical errors.
2. Your health plan wrongly denied the care your doctor ordered, claiming it was not medically necessary.
3. Services or medication that your doctor ordered was denied coverage because of a failure to get prior authorization.
4. Your health plan made a mistake by denying a claim for a service that is covered by your health plan.

If you believe your health plan should pay for your care, pull together the information you need.

1. Review the claim denial letter shared with you from your health plan and compare it to the bill you received.
2. Write down any questions you have. Ask your doctor or health plan for anything you don’t understand. Get the name of the person providing answer. Write down the time, date and phone number when you spoke to them.
3. Request a full claim file from your health plan. The file will provide more information about your specific claim denial. Use this tool from ProPublica to help you get started.(NOTE: ProPublica does not store any information you enter into this form without your consent.)
4. Don’t delay – file an appeal: Use the phone number on the back of your insurance card or visit your health plan website to understand your  plan’s required appeal process. 

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 had with your insurer and providers. 

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. Remember, you can login to see your claims at any time on your online Medicare portal. 

Step 2: Move quickly to appeal. To appeal denial of drug coverage, you have 65 days from the date on the initial notice of denial. 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. 

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. 

For more details on the entire Medicare appeals process, including deadlines, follow this guide. 

For those with private insurance: 

Start with an “internal appeal.” The health plan will review their own denial decision based on the information you submit. 

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 health plan 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.

For more details on the appeals process for health plans purchased on the federal marketplace (healthcare.gov), including deadlines, follow this guide. 

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.