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Know Your Rights: How to Appeal a Denied Health Plan Payment

The first step is making sure the denial wasn’t made in error.

Just because a health insurance company says it will pay only part of your claim, that doesn’t mean you just have to accept the decision. You have the right to appeal — as long as you do so within the prescribed amount of time — usually 180 days of receiving a notice your claim was denied.

But first, make sure you understand why your claim was denied and what steps you need to take to properly appeal a decision. It pays to take the time to read your policy, check your insurance company’s website or talk to customer service to better understand what your policy is supposed to cover. You also must understand the difference between a rejected appeal and a denied appeal.

A rejected appeal occurs when the claim could not be processed due to incorrect information. Rejected claims do not need to be appealed. You only need to correct the error on the health insurance claim form. Then resubmit it for the insurance company to reprocess the claim.

A denied appeal results when an insurance company does not approve payment for a specific procedure, test, or prescription. Some reasons your appeal may be denied include:

• Your health insurance plan does not cover that particular service or procedure.

• You have exceeded the coverage limits in your plan.

• The drug or therapy is not covered by your health plan.

• You may have used out-of-network services when your health plan requires “in-network” providers.

If you believe that none of these reasons applies to your claim, you can request an internal appeal, which will be conducted by the insurance company. If they reject your claim a second time, you can request an external appeal conducted by an independent third party.

Internal Appeals

You should receive an explanation from the insurance company about why your claim was denied and the steps you can take to appeal the decision.

Before calling an insurance company representative, find your policy information, the summary of benefits and the denial letter. Prepare a list of questions. Take notes and get the name of the person you’re talking to and the date and time of the conversation. This might fix the issue if the claim was denied because of a simple error.

However, if your claim wasn’t denied because of error, you must write the insurance company a formal letter asking them to reconsider the claim. Your letter should include:

• The service, treatment, or therapy that was denied and the reason for the denial.

• A request that they appeal the decision.

• The claim number.

• History of your medical condition or health problems.

• Explanation of why the treatment is or was medically necessary.

• Supporting information from your doctor, such as a letter.

• Evidence, such as medical records, X-rays and lab results.

Remember that you can ask for an expedited appeal if you or your doctor thinks the denial of your claim is life-threatening.

Independent External Review

You can ask for an independent external review if your claim is still denied after an insurance company internal appeal. Many states have an external review process. If they don’t, the federal Department of Health and Human Services will oversee the review. Your explanation of benefits or the final denial of your internal appeal should have the contact information about who will handle your external review.

You must file a written request for an external review within 60 days of the date your insurance company sends you a final decision on your internal appeal.

Please Contact Us if you have any questions.

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