Seven Steps to Appeal a Denied Medical Claim
Find out what to do if your insurance carrier denies a claim for arthritis-related care or other health services.
If you’ve received a letter from your insurance company denying coverage for an arthritis-related medical test, procedure or treatment, don’t take out your checkbook just yet – take action. Here are seven steps to help reverse the decision, and preserve your financial health.
1. Review Your Insurance Policy
Read through your policy again, to see if it covers the denied treatment.
2. Call the Insurance Company
Have detailed information about the claim with you when you call, including notes from conversations with your doctor, and a copy of the Explanation of Benefit (EOB) – the form the insurance company sent denying the claim. Be ready to tell the insurance company the date(s) of service, the diagnosis and other key facts about your case. Ask why you were denied coverage, and how you can appeal the decision.
3. File an Internal Appeal
Ask your insurance company to review its decision. You must do this within 6 months after learning your claim was denied. To file an internal appeal:
- Review the appeals process, which should be outlined in the rejection letter from your insurance company.
- Fill out the appeal form(s) your insurance company provides.
- Ask your doctor to write a letter or provide other background material to help your case.
- Call in the Consumer Assistance Program in your state to file an appeal for you, or contact your state’s insurance commissioner’s office for more assistance in appealing the denial.
Once the internal appeal review is finished, you should get a written decision in 30 to 60 days. If the claim involves a serious health issue, ask the insurance company to speed up the process.
4. Check with Your Doctor
Ask your doctor if you need to make payments on the disputed bill before the appeal process is completed, and get the response in writing. Legally, your doctor can turn your account over to a collection agency, even if your bill is in dispute.
5. Get an External Review
If your appeal is rejected, you can ask for an external review of your claim. That means an independent person outside of your insurance company will do the review. To request an external review:
- Submit a written request for external review within 60 days of the date you received the insurance company’s decision.
- Or, ask a doctor or other medical professional to request the review for you by filling out an Appointment of Representative form.
If the external review rules in your favor, the insurance company will have to pay the claim. However, the reviewer may stick with the insurance company’s original decision.
6. Contact the Drug Company
If you’ve been denied coverage for a medication, contact the drug’s manufacturer. Many pharmaceutical companies offer resources to help people whose insurers deny coverage for their medicine. (See the pharmaceutical company resource list for this information.)
7. Don’t Take “NO” for an Answer
When pursuing appeals for denied services or drugs, be persistent. You and your doctor may be able to reverse the decision based on your medical need for that service or drug.
Get general information about filing appeals.
Find your state’s Consumer Assistance Program.
Start the external review process.
To get help filing an internal appeal or external review, visit your state’s Department of Insurance.