Arthritis Today

Benefit Denial Checklist

Seven Steps to Protecting Your Finances


If you’ve received a letter from your insurance company saying coverage for a medical test, procedure or treatment has been denied, don’t take out your checkbook just yet – take action. Here are seven steps you need to take to help preserve your financial health.

1. Review your insurance policy first and determine if the denied treatment is expressly excluded in your policy.

2. Keep detailed notes about when you were denied, and why you were denied, for coverage, and other key facts about your case.

3. Speak to your insurance company through its toll-free customer service line for immediate response. Before you call the insurance company, having the following information readily available will help the conversation go more quickly and smoothly:

a. a copy of your insurance card showing the policy and group number
b. a copy of the Explanation of Benefit (EOB) – the form that was sent by the insurance company denying the claim
c. the code on the form that shows why the claim was denied
d. the date (s) of the service (s) that were denied
e. the specific diagnosis for which the service was denied

4. Contact your doctor and enlist his or her help in appealing the denial. Your doctor can appeal the denial in writing. Be patient; the appeal process may take 30 days or longer to be processed. Also, ask your doctor if you need to make payments on the disputed bill before the appeal process is completed – and ask for everything in writing.  Legally, your doctor can turn your account over to a collection agency even if your bill is in dispute.

5. Contact your state’s insurance commissioner’s office for more assistance in appealing the denial.

6. If coverage for a medication is denied, consult the Web site or toll-free information line of the company that manufactures the medication. Many pharmaceutical companies offer resources to help people whose insurers deny coverage of the treatments they produce, including on-call operators to provide guidance. (See the health care resource list for this information)

7. Do not take “NO” for an answer. Be persistent in pursuing appeals for denied services or drugs. If there are no contractual limitations or specific policy exclusions under your particular insurance plan, you, along with your doctor may be able to reverse the denial decision based on the medical necessity of the service(s) or drug(s) for your arthritis.

Above all, don't give up. Use all available resources to help you navigate the insurance maze.

Learn more helpful information about navigating the health care system from the Arthritis Foundation. The Kaiser Family Foundation also offers a free guide to handling disputes with your employer or private health plan.