Help! What Can You Do If Your Health Insurance Claim Is Denied?

When it comes to your medical care, or the medical care of a family member, the last thing you want to worry about is whether or not your health insurance provider is going to foot the bill. Unfortunately, medical claims do get denied for all sorts of reasons. Fortunately, you do have the right to appeal any denial. In fact, you have 180 days (6 months) from the day you received the denial to file an appeal. The question is – how much do you know about filing an appeal?

You Have Two Options

When filing an appeal for health insurance coverage denial, you have two different options to consider. First, is the internal appeal. This means you want the health insurance provider to take a second look at your case and reconsider why they denied your claim and why you think they shouldn't have. Your second option is to have an external appeal. This means you want a third party – someone who is not affiliated with the insurance company – to take a look at your case and determine whether or not the denial was justified based on your policy plan. It is not uncommon for someone to file an internal appeal first and then final an external appeal if the internal appeal ends up resulting in a second denial.

What Should You Know Before Filing The Appeal?

Before you file the appeal, there are a few things you should know or do. These steps are going to increase your chances of the denial getting reversed when you file the appeal.

Understand Why The Claim Was Denied: First, you need to have a clear understanding as to why the insurance provider decided to deny your initial health insurance claim in the first place. Your denial will come with a letter explaining why you were denied. In most cases, the insurance provider will use codes to explain this to you. The denial usually comes with a key that explains what the codes mean as well. If you are still not sure why you were denied coverage, call the insurance company and have them explain it to you in a way that you understand. You have this right and the insurance company has an obligation to explain it.

Fix Easy Stuff First: It is not uncommon for a health insurance claim to be denied simply because of a data entry mistake. This could be as simple as someone misspelled your name or entered the wrong date for when the medical care was received. Take the time to read through everything and make sure there was not a data entry problem. If there was, you should talk to the insurance provider and see if the data entry problem could have resulted in the denial. If so, you can just file the appeal with the correct information included.

If getting the denial reversed doesn't seem to be an easy fix and there were not any data entry errors, you may need the assistance of an insurance claim denial attorney. Don't hesitate to reach out to a claim denial lawyer if you feel your health insurance provider is denying a claim they should be paying for.