Understanding Health Care Bills: How to Appeal Denied Claims

How to Appeal Denied Claims

When you use medical services, you or your provider

ﬁle a claim to your health plan. Most of the time, the

health plan will pay the claim, either directly to the

provider or to you if you have already paid for your

medical care.

Sometimes your health plan will say “no” to a claim,

in full or in part, for beneﬁts or services you believe

should have been covered. Here are the steps you can

take:

. . . If Your Health Plan Says “NO”

You have the right to appeal your health plan’s denial

of beneﬁts for covered services that you and your

health care provider (doctor, hospital, etc.) believe are

medically necessary.

There are two kinds of appeals—internal appeal and

external review

Filing an Internal Appeal

By ﬁling an internal appeal, you are requesting your health plan to

review the denial decision in a fair and complete way. You have up to

six months (180 days) after ﬁnding out your claim was denied to ﬁle an

internal appeal.

· If the denial is for a medical reason, ask your health care provider

to contact your health plan to request reconsideration of your claim

based on additional information that your provider can supply.

· If your life, health, or ability to function could be jeopardized, you

can request that the appeal be reviewed on an expedited basis.

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2 NAIC / UNDERSTANDING HEALTH CARE BILLS: HOW TO APPEAL DENIED CLAIMS

· Ask your health plan how to ﬁle an internal appeal by contacting the

customer service number provided on your insurance card /materials,

· Write a letter to your health plan requesting an internal appeal. Make

sure to include your name, claim number, and health insurance ID

number. You should include any additional information, such as a letter

from your provider, that helps support your claim. (See next page for

sample letter.)

Upon receiving your request, your health plan has a speciﬁc amount of

time to review and issue a decision on the internal appeal.

. . . If Your Health Plan Still Says “NO”

Filing an External Review

If your health plan does not change its decision as a result of the internal

appeal, an external review can be requested. An external review is

performed by an independent review organization. You must ask for

an external appeal within a speciﬁc amount of time after receiving the

decision of your internal appeal.

· Your internal appeal notice should provide information on requesting

an external review.

· Your state’s insurance regulatory agency is usually in charge of the

external review process.

· New information can be submitted to support your position.

· The external reviewer will provide you and your health plan with

written notice of its decision within a speciﬁc amount of time after

receiving the review assignment.

· If the external review results in a reversal of your health plan’s decision

to deny, the company must approve beneﬁts for the covered services.

If you have questions or think your health plan is doing something wrong,

contact your state insurance regulatory agency. A directory of all state

insurance regulatory agencies is available at naic.org.

3 NAIC / UNDERSTANDING HEALTH CARE BILLS: HOW TO APPEAL DENIED CLAIMS

Sample letter to request an internal appeal

Your Name

Your Address

Date

Address of the Health Plan’s Appeal Department

Re: Name of Insured

Plan ID#:

Claim #:

To Whom It May Concern:

I am writing to request a review of your denial of the claim for treatment or

services provided by name of provider on date provided.

The reason for denial was listed as (reason listed for denial), but I have

reviewed my policy and believe treatment or service should be covered. Here

is where you may provide more detailed information about the situation.

Write short, factual statements. Do not include emotional wording. If you are

including documents, include a list of what you are sending here.

If you need additional information, I can be reached at telephone number

and/or e-mail address. I look forward to receiving your response as soon as

possible.

Sincerely,

Signature

Typed Name

4 NAIC / UNDERSTANDING HEALTH CARE BILLS: HOW TO APPEAL DENIED CLAIMS

Things to Keep in Mind

Medicare & Medicaid

If you are enrolled in Medicare or Medicaid, there are

different rules for appeals.

· For Medicare, call 1-800-MEDICARE to ask for

information on free assistance.

· For Medicaid, contact your state’s Medicaid agency

for assistance.

Keep Records

Keep detailed records, including bills from your provider, notices from

your health plan, copies of denial letters, appeal requests and medical

information related to your case.

Take Detailed Notes &

Establish Response Deadlines

Write down the date/time of all calls, names of people with whom you

spoke, details of all conversations and any established deadlines for

expected responses or information from your insurance company.

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