My Claim Was Denied – Now What?
It’s a terrible feeling to open a letter from your insurer and find you owe more money than you thought. Maybe your insurer paid less for a procedure than you expected. Or, maybe they denied a payment entirely. What do you do now?
The first thing to do is talk to your insurer and find out why the claim was denied. It might have been a simple mistake. Maybe your healthcare provider used the wrong code for your treatment when submitting the claim. Or, maybe you got prior authorization like you were supposed to, but your insurer didn’t realize it. If it was just an error, your provider may be able to help you clear up the confusion with your plan.
But, maybe it wasn’t a mistake. The claim may have been denied because, for example, your insurer did not find the treatment medically necessary, considered it experimental, or doesn’t cover the service at all. In that case, you have a legal right to appeal. That means that you can formally ask your plan to reconsider their decision.
(Keep in mind that if your claim is denied because your insurer doesn’t cover that service – say, cosmetic dentistry – your appeal will most likely be denied, too, because that service is simply not part of your plan.)
How Do I Make an Appeal?
Different types of plans must meet different laws and regulations for appeals. So, you need to make sure you follow the appeals process that applies to your particular plan.
Your insurer’s customer service representatives should be able to give you the detailed instructions on how to make an appeal. This information, as well as appeal forms, may also be available on your insurer’s website or in your plan documents. Your Explanation of Benefits from your insurer may also include a statement about how to appeal a decision.
Keep in mind that at each level of appeal, different plans may have different timeframes and deadlines for submitting the appeal documents, so be sure to familiarize yourself with these dates.
How Does it Work?
The appeals process is structured so that you have more than one chance to get your decision reviewed. If your appeal is denied, you can go to the next level. But remember, some insurers may need to follow different rules and policies about appeals. You will need to make sure you know the appeals process for your particular plan.
Generally, the process works like this:
Remember: there are time limits to submit your appeal at each level, and your insurer is required to respond to you. For this reason, it's also a good idea to make sure that you have all of your paperwork ready when you file your appeals.
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Where Can I Find More Information?
The first thing to do is check your plan booklet, your insurer’s website, or call your insurer so you can be sure you understand how your plan’s appeal process works.
If you get health coverage through your employer, your plan may have to follow regulations set by a law called ERISA (it stands for the Employee Retirement Income Security Act). ERISA has specific rules about the timelines for appeals, your rights, and the kind of information that your insurer must give to you. Your plan may have to follow certain state laws, too.
Some helpful information on ERISA appeals is here.
Many plans also have to follow new rules set by the health reform law as of September 23, 2010. You can find more information on those rules at the official healthcare reform site www.healthcare.gov, here.
Also be sure to visit Healthcare Resources for organizations and resources that may be helpful for the appeals process. One such organization is The Jennifer Jaff Center.
Your Action Plan: Be Informed
The easiest way to deal with a claim denial is to stop it from happening in the first place. Make sure you understand the services that your plan covers, and the rules that you need to follow.
Before you get treatment, ask:
If a claim is denied:
And most importantly – remember that you are your own best advocate. Speaking up and asking questions up front will help you get the information you need to avoid claim denials and high out-of-pocket costs.
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