How to Appeal Health Insurance Claim Denials

Common Reasons Claims Are Denied, and How to Write a Claims Appeal Letter

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Sometimes you must fight for your rights when it comes to health insurance. Mistakes can cause valid claims to be denied. To launch a winning appeal, you need the facts.

First, learn why the claim was denied. It could be an error in how the claim was entered into the insurance system. Maybe a claims processing agent made a mistake. There could be information missing. Do your research.

All health insurers have ways to appeal unpaid claims. If you know how to fight a denied health insurance claim, it may get covered after going through that process.

Key Takeaways

  • If you don't know why your claim was denied, you can't mount a strong appeal.
  • An effective appeal letter contains a clear opening statement, an explanation of your medical condition, and supporting data from your doctor.
  • If your claim was denied because it clearly did not fall within what your policy covers, it may not be worth the effort of writing an appeal.

Denied Claims vs. Rejected Claims

A health insurance claim denial occurs when an insurance company does not approve payment for a specific claim. In that case, the health insurer decides not to pay for a procedure, test, or prescription.

A claim rejection, on the other hand, can be easy to correct. A rejected claim is one that is not processed, because incorrect information is submitted with the health insurance claim form. Rejected claims do not have to be appealed. Simply correct the error. Resubmit the right information, and your insurance company will begin to process the claim.

5 Reasons a Health Insurance Claim Could Be Denied

Knowing why your health insurance claim was denied is key. It lets you know whether you can appeal the decision. If your appeal succeeds, the company must pay for the claim even though it was denied at first.

Here are five common reasons health insurance claims are denied:

  1. There may be incomplete or missing information in the submitted claim documents, or there could be medical billing errors.
  2. Your health insurance plan might not cover what you are claiming, or the procedure might not be deemed medically necessary.
  3. You may have maxed out the coverage limits in your plan.
  4. The drug or therapy is off-formulary and not part of your health plan.
  5. You may have used out-of-network services or used your health insurance out of state when your health plan requires "in-network" providers.

How to Fight a Health Insurance Claim Decision

You will receive a denial notice if your health insurance claim is denied. The notice should tell you how long you have to appeal the decision. It is crucial that you not miss your deadline.

Before you begin the appeal, find out why your claim was denied. Appeals won't always make sense if your plan clearly states that the service you need is not covered, you were out of network, or you have maxed out the coverage limit for the year.

If you're not sure, review your health insurer's website. You can also call to better understand your health insurance policy coverage and the reason for your claim denial.

Write an Appeal Letter to Fight a Claim Denial

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

If you request an appeal but can't share why your claim was denied, the insurance company may find it hard to review your appeal. Talk with someone in the claims department to make sure you understand the reason for the denial and how the appeal process works.

To avoid delays, follow the appeal procedure exactly as outlined. Double-check it before you send it. You want the information they request to go to the right department or person.

What Your Appeal Letter Should Include

A health insurance claim denial can frustrate you to tears. Keep the emotion out of it. A simple appeal letter that gets straight to the point is the best approach. Your appeal letter should be "matter of fact" in tone. Include any information your insurance company tells you is needed.

Your appeal letter should include these things:

Opening Statement

State why you are writing and what service, treatment, or therapy was denied. Include the reason for the denial. Your intro can state: "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."

Explain Your Health Condition

Outline your medical history and health problems. Explain why you need the treatment and why you believe it is medically necessary. List any treatments you've already tried. Explain why you believe that the current treatment may be a solution.

Get a Doctor to Support You

You need a doctor's note. Ask them to support you with information that verifies your statements about your health and the treatment. If the treatment is new, provide documentation from recognized institutions, such as hospitals and medical schools, that shows it as part of a recognized treatment plan.

Send your appeal on time by certified mail. You want to have proof that you submitted your request within the time limit. If appeals are accepted only online, keep records of all emails showing the time it was sent.

When looking to appeal a health insurance claim denial, the key is to understand your coverage and why your claim was denied.

Frequently Asked Questions (FAQs)

How often are health insurance claims rejected?

Insurers who work with are required to provide a greater level of transparency than some other healthcare groups, so the best data on claim rejections comes from those insurers. In 2019, roughly 17% of in-network claims were denied. On an individual insurer level, the average denial rates ranged from less than 1% to more than 50%. By plan type, catastrophic plans had the highest average claim rejection (20%).

How do you get affordable health insurance?

If you don't have access to affordable health insurance through an employer, there are government programs you can consider using. Obamacare's health insurance marketplace can connect you with insurers while helping you understand tax subsidies available to help you pay for premiums. Check with your state government to see whether you qualify for Medicaid or another state-level insurance program. If a family member has good health insurance, you may also be able to be added to their plan at a reasonable price.

Article Sources

  1. Patient Advocate Foundation. "How to Appeal Health Insurance Claim Denials."

  2. Kaiser Family Foundation. "Claims Denials and Appeals in ACA Marketplace Plans."