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Health Insurance Claim Denied? How to Appeal the Denial 

In times of illness or injury, the last thing you need to worry about is your health insurance coverage. If a health claim has been denied, here are some tips to help you understand what you can do.  

TOP CONSIDERATIONS 

Why a claim gets denied: In some cases, a simple error could be why your claim was denied. Your provider's billing staff may have entered an incorrect code, or your claim may have accidentally been sent to the wrong insurance company. This type of error can usually be cleared up quickly with a single phone call. But sometimes the reason can be more complex and require additional steps to get resolved.  

The appeals process: Your policy should indicate how to appeal a denial. There are typically two levels of appeal: a first-level internal appeal administered by the insurance company and then a second-level external review administered by an independent third-party. Your state insurance department will be able to explain the appeals process in more detail. 

Timelines for appeals: Generally, your insurance provider must make a decision regarding your internal appeal within the following timelines after receiving your request: 

• 72 hours if you're appealing the denial of a claim for urgent care. 

• 30 days for treatment that you haven't received yet. 

• 60 days for treatment you have already received. 

THINGS YOU SHOULD KNOW  

Contact your insurance company: If you receive notice that your claim was denied, call your insurance company. You should find contact information on the back of your insurance card and the denial notice. Before you call: 

• Make a list. Have handy all the questions you have about your claim’s denial as well as the details of your treatment. 

• Gather all important documents. This includes your policy, the Summary of Benefits Coverage (SBC), and your denial letter.  

• Keep notes of all conversations you have with company representatives. Make sure to note who you speak with, as well as the date and time you spoke. Ask for the person’s phone extension so you can contact them directly the next time you need to call.  

If your insurer continues to deny your claim, be persistent: The usual procedure for appealing a claim denial involves submitting a letter to your insurance company. Make sure to: 

• Give specific reasons why your claim should be paid under your policy. 

• Be as detailed as possible when composing your letter.  

• Explain why your procedure or medication is necessary. 

• Include evidence that supports your claim. This could include medical records like x-rays, lab results, or a letter from your physician that explains why your treatment is medically necessary.  

• Ask to expedite the appeal if you or your doctor feels that the denial of your claim could be life-threatening.  

• Keep copies of everything you send to the insurance company for your records. 

• Contact your state Department of Insurance if you feel your insurer is not cooperating with the appeals process.  

TOP THREE THINGS TO REMEMBER 

1. If a claim is denied, don’t panic. It could be a simple error that is easily fixed with a phone call.  

2. When contacting your insurance provider about the denial, make a list of questions and gather all important documents beforehand. Keep detailed notes including the name, title and phone number of the person you spoke with.  

3. When appealing the claim be persistent. Send your insurance company a note, being as specific as possible about why your claim should be paid and including as much evidence as you can to support your argument.