What if my Insurance Denies my Claim? 

Summary: Too frequently, insurance company’s deny the claims for orders, procedures and testing that doctors feel that their patients need. Do you know what to do if you receive a denial claim? Here you can read about the steps to take to file an appeal or internal review, plus learn about each type of insurance company and how they handle these claims. While it can be extremely stressful to receive denial letters, they are not the end all of your treatment. Stand up for yourself and take action!

Insurance companies do deny claims, sometimes without any reasoning. In some cases, they will not cover a test, procedure, service, or medication that your doctors have ordered. There are steps you can take with your insurance company to appeal their initial decision. This also applies to Medicare and Medicaid. If your insurance plan refuses to pay for or approve your claim, you have a guaranteed right to appeal. These rights were created as a result of the Affordable Care Act.

When you receive your denial letter, read over it carefully as it will contain all of the information you will need for your appeal and outlines why your insurer denied your claim initially.

Your insurer must provide to you in writing:

  • Information on your right to file an appeal
  • The specific reason your claim or coverage request was denied
  • Detailed instructions on submission requirements
  • Key deadlines to submit your appeal
  • The availability of an assistance program, if available in your state

Reasons that your insurance may not approve a request or deny payment:

  • Services are deemed not medically necessary
  • Services are no longer appropriate in a specific health care setting or level of care
  • The effectiveness of the medical treatment has not been proven
  • You are not eligible for the benefit requested under your health plan
  • Services are considered experimental or investigational for your condition
  • The claim was not filed in a timely manner

Remember, prior authorization does not mean or guarantee your claim will be paid. Think of your appeal as a contract dispute over the interpretation of your plan’s details. Your health plan language defines and explains your contract. There are varying levels of appeal. If the first round of appeals is denied, you have other options and more levels of appeals to work through. This information should be defined in your denial documentation.

If you have medical bills that are overdue for services that have been done, work with your providers directly so that these bills are not sent to collections while the appeals process takes place. For the record, your insurance company cannot drop your coverage or raise your rates because you ask them to reconsider or appeal a denial related to care.

Contact your insurance company and find out how long you have to file your internal appeal. If your insurance plan denies your claim, they must explain to you your rights to appeal the decision. When you ask for this information, they are required to give it to you. You can ask these questions of the customer service representatives or case managers at your insurance company before you make the formal appeal. In certain cases, you can re-submit the claim with a copy of your denial letter and your doctor’s notes and explanation, along with all other written information that supports using the treatments or testing that has been denied. Frequently, the insurance code was wrong on your paperwork and needs to be resubmitted.

Filing your Formal Appeal

When you are ready to question or challenge the denial and the standard methods do not work, you may need to do any number of these things:

  • Request a written response. Keep the originals of all the letters you get; your cancer team may be able to help you make copies if you need them.
  • Keep a record of dates, names, and conversations you have about the denial.
  • Formally appeal the denial in writing, explaining why you think the claim should be paid. Your cancer care team members including your doctor, nurse, and social workers may be able to help with this.
  • Get help from the consumer services division of your state insurance department or commission.
  • Do not back down when trying to resolve the matter.
  • Consider legal action. If you need to, reach out to a lawyer specializing with medical insurance claim denials.
  • Find out if you live in one of the US states that also have a special Consumer Assistance Program (CAP) that can help you file an appeal. You find out online at www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/. If you do not live in a CAP state, get help from the consumer services division of your state insurance department or commission. Contact the National Association of Insurance Commissioners online or you can call them at 1-866-470-6242.

If your internal appeal is denied, you might be able to file an independent external review by people outside of your health plan. Check with your insurance company about this process. If your health situation is urgent, you may be able to rush this external review, and complete it at the same time as your internal review. You can also reach out to the United States Department of Health and Human Services for information about these processes.

Unresolvable Issues with Your Health Plan

When you have exhausted your internal and external appeals and your claim remains denied, ask your health care provider if the cost of the bill can be reduced. Many providers are willing to reduce bills to get paid faster. Here are definitions of varying types of plans and how you can work through the denial and appeal process.

Private group plans or fully insured plans purchased from insurance carriers by employers as a benefit for employees are usually overseen by the insurance commissioner or department of insurance in each state. You can find your state’s insurance department by contacting the National Association of Insurance Commissioners.

Self-funded plans or self-insured plans are health plans that employers or unions create just for their employees and their families. They are overseen by the United States Department of Labor’s Employee Benefits Security Administration. Because employers often contract with insurance companies to administer these plans, it is difficult to tell if a work-based plan is self-insured. You will have to ask your employer if your health plan is self-insured.

Individual plans sold through the health insurance marketplaces are regulated by a marketplace board in every state. This state board oversees the function of the marketplace and the plans sold within it.

Managed care plans are regulated by several state and federal agencies. Your state insurance commissioner or department of insurance can provide specific information about an individual plan.

Medigap policies or Medicare Supplement Insurance policies are regulated by federal agencies, as well as some state laws. Contact the Centers for Medicare and Medicaid Services (CMS) and/or your state department of insurance for information.

Medicaid and CHIP are joint programs that are controlled by your state health department and the federal Centers for Medicare and Medicaid Services.

Medicare is run by the federal Centers for Medicare and Medicaid Services.

TRICARE is overseen by the United States Department of Defense.

The Veteran’s Health Administration is regulated by the United States Department of Veteran’s Affairs.

During your appeals process and working through this denial claim with your providers, insurance agency and creditors, remember you cannot simply leave the bills to deal with another day. Doing this can result in creditors stepping in and taking property, collateral, or monetary funds. In some cases, if you do not work with your providers, they can cease your treatment plan and care. If you are struggling with monetary issues, medical bills and general stress from these denial claims, reach out to an attorney or financial planner who can help to get your finances back on track.

Resources Used:

NIH

ACS

Reclaiming Intimacy

www.cms.gov

www.tricare.mil

www.va.gov/health/

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