Last Revised: 02/12/2019
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How do you know if your claim for treatment was denied?
An Explanation of Benefits (EOB) which is sent to you by your insurance company is one of the only ways to determine what the insurance paid, and how much you may still owe. The EOB should also disclose if your claim has been denied.
If the insurance company portion of the payment shows $0, this can indicate that they denied your claim. The payment amount should be followed by a “Reason Code(s).” This code provides an explanation for the lack of payment. The insurance company may also send you a letter confirming the denied medical claim and detailing their reason(s) for denial.
Make sure to keep copies of all correspondence you receive from the insurance company, including denial letters, approval letters, your health history, medical files, doctor’s letters, etc. Always keep written records of all contacts and phone calls with the insurance company; including the name(s) of the people that you spoke too.
A Coverage Denial is not the Final Word
Many insurance companies deny claims simply because they know there is a good chance the policy holder will not fight back, or appeal.
If your insurance company denies coverage, follow the steps below:
Step 1: Check your plan to make sure the benefit you want is included. Make a note of the part of the policy that leads you to believe your claim should not have been denied.
Step 2: Collect and organize all information pertaining to the denied claim. Make sure you have the original bill with the date of service and the provider’s name, your EOB, and your insurance card before placing a call. If the insurance company sent you a letter, have that available as well.
Step 3: Call the number provided on the letter from your insurance company, or if you did not receive a letter the customer service number. There is a possibility the claim was denied because of missing information. Once the missing information is provided the claim will be re-processed, and hopefully you are done.
Step 4: Sometimes claims are denied because of improper coding. If that’s the case, ask your doctor to review the coding and re-submit a request with more specific medical justification for the procedure or medication, and you should be done.
Step 5: If your claim was not denied for missing information or improper coding, find out why it was denied, and how you can file an appeal.
Step 6: Ask the insurance provider’s representative for suggestions or guidelines for appealing a denial.
Step 7: If you would like an appeal form, ask them to send one via the mail or email.
Step 8: Make sure you have the address for the appropriate department to return the completed appeal documents.
Step 9: Always keep a record of the date, time, and the name of the insurance provider representative you talked with, along with a summary of the discussion. Keep this with copies of any documents you send to the insurance company.
Step 10: In appealing the denied claim, you should have the opportunity to review the information the insurance company used to make their decision.
Step 11: If necessary, get your doctor involved. To win an appeal you’ll likely have to to prove that the test or treatment is “medically necessary” and “scientifically proven.” Your doctor’s office should have staff that can help.
Step 12: Get help wording your appeals so that they mention medical problems, and do not include words that automatically trigger denials. Talk to the person who handles insurance claims at your doctor’s office. This person may be able to help you with the appeal process, and they may provide any documentation your insurance company requires.
Step 13: Remember each insurance company has its own appeal process. Before submitting your information, make sure you have completed and include the required paperwork. Once the documents are complete make a copy of everything for your reference.
Step 14: Continue to go through all levels of appeal.
Step 15: If your insurance company denies the claim again, in most cases you can contact them to request an external appeal. Usually, this appeal will be conducted by a medical professional or group of medical professionals not associated with the insurance company.
Step 16: Sometimes it takes the threat of a lawsuit to get your insurance company to move.
Send your correspondence to the insurance company via certified mail with return receipt. Be persistent. Remember that a denial is not necessarily the final word. Request in writing that your insurance company to reconsider their decision.
Contact your health insurance company within a reasonable amount of time if you don’t receive a written response that includes a justification. If you’re denied again and you believe that this is not consistent with your policy, contact your state insurance commission. That agency can mediate a dispute between you and your insurance company. If you win, you could save yourself hundreds or even thousands of dollars.
Medicare appeals need to follow a separate, federal appeals-review process. There are detailed instructions for each level on the CMS website.
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