How to Appeal a Rejected Insurance Claim: Step-by-Step

Learning about how to appeal a rejected insurance claim can be an overwhelming and lonely battle for any person. That official looking envelope comes in and those words, “denied” or “not covered” seem to be a punch in the gut. You paid your premiums. You trusted the system. Now, you’re left with stress on your hands and a massive bill that you may have to pay.

However, it is very important to understand that a denial is not the end of the road. In fact part of the beginning of a process – a process you have the right to pick your way through. A large number of denials are reversed on appeal. You just need to have a good strategy in mind and the determination to see things through.

This guide will be your one-stop shop to be your roadmap. We will take you through always of the stepsAbbreviabiting that confusing denial letter to escalating your case to a third party reviewer. You have better power than you really think. As a result, with the right information, you can then confidently challenge the insurance company’s decision and fight for the coverage you deserve. Let’s start the journey to appeal a rejected insurance claim together.

The Rejection Letter Has Arrived: Don’t Panic, Strategize

The first emotion you can have when seeing the denial is frustration or perhaps even despair. These feelings and are all completely normal and valid. Take some news processing time.

However, do not let emotion direct your next move. A successful appeal is constructed on logic, evidence and persistence – not anger. Now is the time to change from a patient to a project manager.

Your new project is that you need to make a strong case. This requires organization and being methodical. First, you must collect your tools, and these begin with those documents that the insurer sent to you. Your road to successfully appeal a rejected insurance claim starts here: Understanding exactly why they said “no” in the first place.

Step 1: Decode Your Insurance Denial Letter and EOB

Before you can fight a denial, you need to know about it totally. The insurance company is called upon to give account their specific reason for their decision. This reason is the starting point. There are two documents of key importance here; the letter of official denial and your explanation of benefits (EOB).

Reading the Insurance Denial Letter: What to Look For

The letter of denial of your insurance is your formal notice. It is possible that it is full of jargon, but you need to read it carefully. Look for the some key pieces of information.

First, discover the precise cause for the denial. Insurers often use certain codes or phrases such as “service not medically necessary,” “experimental treatment” or “pre-existing condition.”

Next, name the specific language in the policy that they are referencing to support their decision. This helps you to understand their argument.

Finally, and most important, find out the time limit within which to bringing an appeal. This is a hard deadline that you do not want to miss. Missing it could lose your right of challenging the decision. It is an important step in the process to appeal a rejected insurance claim.

Understanding Your Explanation of Benefits (EOB)

Often, the explanation of benefits (EOB) will follow the formal denial letter. Many people confuse it with a bill, however, it is not a bill. It is an insurance company statement.

Provide a record of what the provider charged, what the insurance company paid, and what you have to pay. It will also include reason codes for the reasons a charge was changed or denied.

That is why it is important for you to compare your EOB to the insurance denial letter. They should convey the same story. If there are discrepancies, it could mean a simple clerical or billing error – often it is the easiest type of denial to resolve. To understand these documents is basic to your financial defense approach.

Before the Formal Appeal: The Informal Review

In some cases, an expedient in finding a solution is a simple phone call. Previous to starting an insured’s formal appeal against a rejected insurance claim, you may want to attempt an informal inquiry.

Clerical errors are remarkably commonplace. A wrong billing code, a spelling mistake in a name, or the wrong policy number can lead to an automatic denial. A quick call often will allow these relatively minor mistakes to fixed without a full-blown appeal.

To attest to your insurance, call the member services number on your insurance card. Be polite but firm. Have your policy number, the claim number and the insurance denial letter in front of you.

Ask the representative to make the denial simple. Then, ask whether there’s a simple fix to the situation, however, such as resubmitting the claim with a different code. Take detailed notes of the call: the date, time, name of representative, and a number to refer to the call back. This information is vital if there is a need to escalate in the future.

This step may not solve all the problems. But for simple mistakes this can save you weeks of formal paperwork and waiting. It’s a low-effort high reward first move in any insurance claim dispute.

Step 2: The Internal Appeal Process: Your First Formal Challenge

If you’re still not satisfied with an informal call then the second step is the formal internal appeal process. This is an official request and is an asking the insurance company for a full and fair review of their decision. You are asking them to have a second look.

This process is a legal requirement. The insurer must have some system in place for you to appeal their decisions. This is your most important right if you have had to appeal a rejected insurance claim.

You need to file this appeal before the period of time listed in your denial letter, which is usually 180 days for health insurance claims under the ACA. At this stage, a different set of eyes at the insurance company (people who were not involved in the original denial) will looking at your claim and your new evidence. This is your opportunity to make your case by formal means.

In order to have the best case for your ideas, you need to organized. You are going to be collecting documents and evidence to substantiate your side. A checklist can used to make sure you do not overlook something important.

How to Write an Appeal Letter That Gets Results

Your appeal letter is the basis of your internal appeal process. This document must be clear, concise, and professional and persuasive. It is not a place to express your anger. Instead, it is a written business transaction designed to accomplish a specific goal; getting your claim paid off.

Essential Components of Your Appeal Letter

Every appeal letter needs to have some basic information on top. This is to ensure that your correspondence gets routed around correctly and associated with your original claim.

Always put your full name, address and phone number. Also, provide your insurance company policy number and your group number. Finally, mention the exact number of the claim and the date of service for the denied treatment.

Write the letter with a pure, clear, and direct statement. For example: “I am writing in order to formally appeal the denial of claim number Your Claim Number of services rendered on Date of Service.” This does not leave a place for confusion.

Crafting a Persuasive Narrative

After what has been said in the introduction, you have to develop your argument. Don’t simply say that the denial was wrong. You need to explain why it was wrong, but specific things.

Start with a short, single paragraph summary of your medical condition and the treatment that you received. You need to keep it simple and to the point.

Next, get right to the issue of why he/she is being denied. Quote out the reason found in the insurance denial letter and then methodically refute it. For example, if they told you it was not “medically necessary,” this is where you bring out your doctor’s letter on why it was.

Always be positive in keeping a professional and respectful tone. You will be more successful if you are firm and factual instead of emotional and accusatory. This way, your position is strengthened when you are appealing against a rejected claim made on your insurance. This approach strengthens your position as you appeal a rejected insurance claim.

Gathering Your Supporting Arsenal

A letter alone is not enough. You need information to support your claims. The more pertinent, better quality evidence you are able to provide, the more difficult it is for the insurer to maintain his or her denial.

The support of your doctor is of paramount importance. As an alternative, ask your doctor to write an appeal letter, or a “Letter of Medical Necessity.” This letter should explain: your diagnosis, the treatment that you have had, and why it was the proper thing to do based on medical standards.

Besides, collect your relevant medical records. This includes office visit notes, lab and imaging reports. You can also include peer reviewed medical journals or clinical practice guidelines that indicate the treatment that you received is considered standard care for your condition. The task is to create a mountain of evidence. These documents are also a part of the success of the mastery for quick payout tactics in the future.

A Template to Help You Write an Appeal Letter

Here is a shell structure to follow termed too basic:

I am writing to officially appeal your decision to reject the above-referenced A copy of the original claim and your insurance denial letter (date of letter – Date of Letter) is attached.

On Date of Service I received Briefly describe the service or treatment. This treatment was for my diagnosed treatment of Your Diagnosis and was prescribed by my physician, Dr. Doctor’s Name.

Your denial letter states the reason for denial was “[Quote the reason from the letter].” I think this was a decision that was made in error. This treatment was medically necessary and appropriate in my condition.

To support my appeal I have enclose the following documents:

• A letter from Dr. Doctor’s Name indicating the reason of necessity in medical terminology of the treatment.
• Relevant medical records (from Dates).
• Give any other supporting materials, such as studies or test results.

On the basis of this evidence, I request that you reverse your initial decision, and process this claim for payment. Thanks for your time and reconsideration. I anticipate your response within the timeframe required by the state and federal law.

Sincerely,

[Your Signature]

[Your Typed Name]

What to Expect After You Appeal a Rejected Insurance Claim (The Internal Review)

After you send your appeal packet in the mail (always use certified mail with a return receipt), the waiting period starts. Insurance companies must process appeals within a specified period of time.

For the urgent care claims, the review must occur within 72 hours. In the case of non-urgent claims where you haven’t gotten the service yet (pre-authorization) they usually have 30 days. For claims of services that you have already received, they have 60 days. These timelines are mandated by the Affordable Care Act but may differ slightly.

This time, the insurance company will be checking your file. You will have the opportunity for your appeal letter and the supporting documents to evaluated by a medical director or other clinical person. They will compare your evidence to their medical policies as well as the terms of your health plan.

There are three different outcomes. Best case scenario is that they overturn their decision and pay the claim. They might also maintain their denial, meaning you will have to move on to the next step. Occasionally, they may ask for more information before reaching a final decision. While waiting, it’s a good idea to value all your personal safety options to prepared for any financial choice.

Step 3: Escalating to an External Review Insurance Appeal

If the insurance company stands by its denial after the internal process of appeal, it is not the end. You have one more powerful option, which is an external review insurance appeal. This is a crucial step when you have a rejected insurance claim and you are constantly encountering resistance. This is a critical step when you appeal a rejected insurance claim and face continued resistance.

An external review is done by an Independent Review Organization (IRO). These are certified and unbiased 3rd party medical experts that have nothing to do with your insurance company. They will perform a de novo review, which means that they examine the case in a new way from a fresh perspective.

This is your right under the federal law for most types of health plans. The decision of IRO is law on the insurance company. If the opinion of the outside reviewer is with you, the insurer must pay the claim. This process makes a lot of level playing field.

To begin an external review, you ordinarily have 60 days from receiving your final denial from your internal appeal to file a request for performance review. You can get forms and instructions that you need in the final denial letter or by contacting your state Department of Insurance. You can also find extensive resources at Healthcare.gov’s page on appeals.

Understanding Your Rights and When to Seek Help

The appeals process is intended to traveled by a consumer. However, some cases are complex and the stakes may be extremely high. Knowing when to call upon a professional is a sign of strength and not weakness.

You always have to be alert and protect yourself from claim fraud using simple checks while going through this process. This not only helps protect your finances, but it also helps strengthen your case as well.

Navigating an Insurance Claim Dispute with Professional Help

If your claim involves a very high-dollar amount of damages, a complex medical condition, or you just simply do not feel like you are prepared to handle the claim on your own, consider that you may need support to benefit yourself.

Patient advocacy organizations are good sources of guidance and resources, sometime free of charge. They are familiar with the insurance maze.

For a major insurance claim dispute you may want to consider hiring a lawyer who specializes in the field of insurance law. They can handle the entire process for you from writing letters to representing you in the court of law if the need arises. This is especially important if you think the insurance company has bad faith.

Recognizing Bad Faith Insurance Practices

Most claim denials are disagreements over the terms of a policy, or denials of medical necessity, given in good faith. However, in some cases, there is a possibility that an insurance company is involved in bad faith insurance practices.

Bad faith insurance happens when an insurance company attempts to shirk its obligation under a contract to pay a valid claim without just cause. It is a serious problem, which can result in being sued.

Examples include:

• Thinkingly misinterpreting their own policy language.
• Failing to make a timely and comprehensive investigation.
• Unreasonable delay when making payments on an approved claim.
• Making threatening to prevent you from appealing.

If you suspect bad faith insurance, it is very important to contact an experienced attorney right away. You also should make a complaint to your state’s Department of Insurance, which regulates insurers and investigates consumer complaints. This can cause pressure for even established market leaders and emerging brands.

Proactive Steps for Future Claims

While you work on the current battle to appeal a rejected insurance claim, you can also take steps to prevent insurance denials from happening in the future. Being proactive is the greatest way to insure your long-term financial health and wealth growth.

Always try to get pre-authorization (or prior approval) for any major procedure, test or stay in a hospital. This requires the insurer to examine the medical necessity before you have received the service. While it is not a guarantee of payment, it decreases dramatically the likelihood of a denial in the future.

Keep strict records of each and every conversation with your insurance company and doctors. Mercy Smith typed a note below these images to record the date, name, and what was discussed:

Finally, read through & understand your insurance policy. Know what is covered, what is excluded and what you are responsible for on things like travel safety contracts or other specialised plans. An educated consumer is an empowered one that can guard their family savings.

Conclusion: Taking Control of the Process to Appeal a Rejected Insurance Claim

Being denied an insurance claim is daunting, but it is a fight that you can win. The most important thing is to be persistent, organized and informed. Remember about the process: understand the denial, attempt an informal call, file a good internal appeal and if you need to go to an external review.

Each and every step is an opportunity to prove your case. By finding factual evidence, collaborating with your doctor, and effectively communicating the facts, you can hold up your insurance company to the promises made in your insurance policy. The right to appeal a rejected insurance claim is your right.

Don’t place one piece of paper between you and obtaining the care you need or becoming the financially secure person that you are. You have a voice, you have the right and this is the way forward. Now, you know enough to be confident in making an appeal when an insurance claim has been denied. Now, you have the knowledge to confidently appeal a rejected insurance claim.

Frequently Asked Questions (FAQ)