Health Insurance Claim Denials: How to Appeal

Common Reasons Claims Are Denied & How to Write a Claims Appeal Letter

Woman signing forms and letter to insurance company
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Sometimes you have to fight for your rights when it comes to health insurance. When an insurer denies a health claim it could for the right reasons or it could be in error, due to the way the claim was put in or that the person assessing the claim didn’t approve because of a mistake, or that there was missing information. By finding out why a health claim was denied, you're in a position to understand if you should appeal the claim denial. All health insurers have appeal processes that allow people to appeal a claim denial.

You may have a chance to fight your health insurance claim denial and have your claim covered by following an appeal process.

What is a Health Insurance Claim Denial?

A health insurance claim denial is when an insurance company does not approve payment for a specific claim. Knowing why your health insurance claim was denied is an important aspect to knowing if you can appeal the decision to be paid for the claim after a review, even though a claim was originally denied.

5 Reasons a Health Insurance Claim Could Be Denied

  1. Incomplete or missing information in the submitted claim documents or medical billing errors.
  2. Based on coverage in your health insurance plan, does your plan cover what you are claiming? Various plans cover different things and sometimes even though one part of a procedure is covered due to medical necessity, different parts of the series of procedures or tests a doctor may recommend based on your condition may not be considered medically necessary and may not be covered on your health insurance plan.
  1. You may have exceeded the coverage limits in your plan
  2. The drug or therapy is off-formulary
  3. Out-of-network services. If your health plan requires that you are only use "in-network" providers, even though you have the coverage for a service, by going out of network you may have your claim denied. The same can happen if you use your health insurance out of state if you use medical services out of network.

Difference Between Denied Claim and Rejected Claim

A denied claim is when the health insurer has decided not to cover a claim and the claim will not be paid. A rejected claim is when the claim does not get processed, meaning due to an error in information provided when submitting the health insurance claim form, the insurance company did not even look or process the claim due to lack of information or other reason. Rejected claims do not need to be appealed if the claim was rejected you just need to find out why and get the right information to resubmit the claim properly with the additional information the insurance company is requesting.

Can You Fight a Health Insurance Claim Decision?

When your health insurance claim is denied, you will receive a denial notice. The notice should tell you how long you have to appeal. It is very important to check how long you have to start your appeal process and make sure you don't miss your deadline.

Can All Denials Be Appealed?

Be sure and determine the reason why your claim was denied. Appealing a denial when your coverage clearly states something is not covered, you were out of network, or you already exceeded the limit for a coverage does not always make sense. You can check your health insurer's website or call them to understand more about your health insurance policy coverage.

How to Write an Appeal Letter to Fight a Health Claim is Denial

Writing an appeal letter for your denied health insurance claim is a matter of communicating the proper information to have your case looked at as soon as possible.

If you request an appeal and do not know why your claim was denied it may be difficult for you to provide the information they need to review your appeal, so before writing your appeal letter you need to make sure you have spoken to your insurer and gotten the reason of the denial. This puts you in a position to open your appeal with the right information and get an efficient review.

Be sure and ask your insurance company how their appeal process works and what information they need you to provide. Follow their procedure for the appeal and send it to the department or person they tell you to send it to , this will avoid delays.

What to Write In the Health Insurance Claim Appeal Letter?

Keeping your appeal letter simple and to the point is the best approach. Even though a health insurance claim being denied can be a frustrating and emotional issue, your appeal letter should be as "matter of fact" as possible. In addition be sure and include any information your insurance company has told you will be required to appeal, here are some tips on basic things you should include in your appeal letter:

  1. Opening statement: Say why you are writing, what service, treatment or therapy was specifically denied and the reason for the denial. For example your statement could go something like this: "I am writing about claim number 123456ABC. I received a letter denying my claim for XYZ services, for this reason "_____________________" I would like to appeal this decision.
  2. Explain the history of your medical condition or health problems. Explain why you need the treatment (why is it medically necessary). List any treatments you have already tried and why the current treatment may be a solution. Provide documentation from recognized institutions that show the treatment as part of a recognized treatment plan.
  1. Provide any supporting information from your doctor
  2. Send your appeal within the time limits by certified mail so that you have proof that you submitted your request within the time limit.

When looking to appeal a health insurance claim denial the key is to understand your coverage and why your claim was denied. The Patient Advocate Foundation also provides some helpful tips and resources on appealing a health insurance claim denial here.