How to appeal a denied health insurance claim

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BATON ROUGE, La. (WAFB) – What do you do if your health insurance company refuses to cover a test, treatment or medication your doctor thinks is necessary?

Before you dig into your savings and pay out of your own pocket, you have a guaranteed right of appeal, according to Consumer Reports. And the good news is that it’s not that hard.

According to a report by the Kaiser Family Foundation, in 2020 about 18% of on-net claims were denied by people insured under an Affordable Care Act plan.

But that doesn’t mean you should immediately pay for the treatment yourself, or worse, give yourself up. Consumer Reports says you have the right to appeal the decision, and that goes for Medicare or private health insurance.

Step One: Call your insurance company to make sure there hasn’t been an error with your claim. Mistakes can and do happen at several points in the claim or pre-authorization process, and they’re often relatively easy to fix once you’ve identified them.

If there is no error, ask to speak to the reviewer behind the decision and request an explanation. You will need this information for your next step, to submit a formal complaint, specifically stating that you disagree with the decision.

Ask your doctor to write a letter explaining the need for the procedure. You’re used to it, so don’t be afraid to ask. And collect copies of as many other receipts as possible, such as B. Your medical records, treatment studies and previous communication with the insurance company.

The next step might be the hardest: waiting. It may take 30 days or more to get a response, but if you need the denied treatment immediately, make sure you request an expedited review.

If you receive a letter stating that the insurer is still denying the claim, both Medicare and private insurance companies are required by law to provide you with written notice of the reason and how you can appeal the decision for an independent third-party review .

If you buy your insurance through your employer, you should ask your company’s human resources department for help. If Medicare has denied your claim, you may consider seeking legal assistance to have your case heard by a judge.

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