Managing Health Claims, Denials and Appeals

This list of terms will help you understand why a claim has been denied and what steps to take.

Managing the claims process will help to minimize claims denials. If an appeal is necessary, you need to know common appeal terms, understand why your claim was denied and follow the steps of different appeal processes.

Benefits Verification Checklist for Arthritis Medications
Getting access to your prescription medications is critical to managing your arthritis. Follow these steps to ensure you get the drugs you need in a timely manner.

Understanding Your Explanation of Benefits
After you receive a health care service or product and an insurance claim has been filed, you’ll receive an explanation of benefits (EOB) from your insurer. Understanding this document is an important step before appealing a denied claim.

Common Medical Billing Errors
Medical billing and coding errors are unfortunately common. That can cause your claim to be denied or increase what you have to pay out of pocket. Here are a few errors that may cause claim problems.

Common Reasons for Claim Denials
Claim denials usually fall in one of three categories: coverage issues, appropriateness of services and process errors.

Glossary of Appeal Terms and Definitions
Understand commonly used insurance appeal terms and definitions. This is not a complete list and should be used for general information purposes only. Your insurance plan documents may use variations of these terms.

Appeal Process – Commercial, Employer and Health Exchange Plans 
Learn about the important steps in the appeal process.

Appeal Process – Government-funded Plans 
Learn about the important steps in the appeal process.

Sample Appeal Letters
Use these templates to develop your own communication or as examples for your healthcare providers to use.

Communication Log (PDF)
Use this resource to help keep track of your communication as you manage your appeals.

State Of Your Health: Enforcement of Your Rights
In the last two decades, Arthritis Foundation Advocates have played a pivotal role in more than 120 state legislative victories across the country. But what do those victories mean for patients and their access to care?

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