When you use medical services, you or your provider file a claim to your health plan. In most cases, the plan will cover the cost of the claim. However, occasionally, they will refuse to pay. This is called a health insurance claim denial. If your plan denies coverage for medically necessary procedures, you may need to file an appeal.
However, you can file an appeal to dispute the refusal. If you are new to the appeal process, don’t worry! Our experts at My Healthcare Direct have provided a quick guide on how to appeal your health insurance claim denial for the best possible results.
What Are Health Insurance Claims?
Health insurance claims are payment requests to health insurance companies. You should only file claims for covered medical services. Members can file claims for diseases, injuries, illnesses, or health conditions.
Reasons for Health Insurance Claims Denials
To determine whether your claims have been denied, refer to your Explanation of Benefits (EOB). EOBs are written explanations for a claim, showing what costs are covered and what you must pay. If you discover that some of your medical procedures are denied, there may be several reasons.
The following are potential reasons insurers can deny your claims:
- Missing information
- Errors in filing
- Treatment not considered medically necessary
- Out-of-network provider
- Services are not covered
- Late claim submission
- Incorrect patient information
- Missing documentation for claim approval
- Services require pre-authorization or referral
- The claim comes after the submission deadline
Along with breaking down covered costs, insurers will provide the reason for refusal. When in doubt, reference your EOB for answers.
Being aware of the causes of claim denial is essential. For example, you can resolve mistakes, incomplete information, or late submissions. Once you do, you can resubmit the claim for approval.
How Can You Appeal Health Insurance Claim Denials?
When a health insurance company refuses to pay for a claim, you have the right to file an appeal. If you’re wondering how to appeal a health insurance claim denial, there are several steps you can take.
Review Your Policy and Benefits
Before filing an appeal, you need to know what benefits your policy does and doesn’t cover. This gives you an understanding of whether you can file a legitimate appeal. If you file a medical service claim your provider does not cover, an appeal would not be the appropriate solution.
Understand Reasons for Denial
You can understand why your provider rejected your claim using your EOB. It’s necessary to have those answers to determine whether to file an appeal.
The Appeal Process for Health Insurance Claim Denial
When filing an appeal, here’s some critical information you should be aware of:
Internal Appeal
Following a claim rejection, you can request an internal appeal. Then, you have up to 180 days to file.
For your appeal, you must explain why the treatment is medically necessary. Specifically, include details about your condition and recommended treatment plan. You should also attach letters from your healthcare professionals. Those who cannot file a review independently can appoint a representative.
For a healthcare emergency, you can ask for an external review with your internal appeal.
External Review
You must submit the external review within four months after the health insurance claim denial. Upon submission, a third party reviews your case. Insurers may use Independent Review Organizations to evaluate claim refusal objectively. Your insurer is legally required to accept the external reviewer’s decision.
Typically, organizations provide review results as soon as possible or within 45 days. They decide expedited reviews within a 72-hour window or sooner, depending on the nature of the emergency.
Denials Eligible for External Review
Here are the three key types of denials that qualify for external review:
- Judgments where you disagree with the health insurance plan
- Denials involving determinations surrounding an experimental or investigational treatment
- Coverage cancellation due to false or incomplete information on your insurance application
If you need additional help filing an appeal or external review, contact your state’s Consumer Assistance Program (CAP) or Department of Insurance.
Reach Out to My Healthcare Direct for Assistance on Your Appeal!
Knowing how to appeal a health insurance claim denial allows you to resolve healthcare plan issues. For further guidance, rely on My Healthcare Direct. We will provide immediate answers to ease your concerns.
Our health insurance experts will guide you on appeals so you can have your medical services covered. More importantly, we will resolve any issues that arise during the process.
Contact us today to speak with one of our health insurance specialists!