How to Appeal a Denied Health Insurance Claim
Have you recently received a letter from your insurer denying coverage for a test, medication or other medical treatment?
If so, you’re not alone, whether you get insurance from your employer, buy it yourself, or have Medicare coverage. A recent study, for example, found that 17% of claims by people insured through an Affordable Care Act market plan were denied in 2018. Another study, looking at people covered by an leading insurer Medicare Advantage, found nearly a third had at least one claim denied over a one-year period. These refusals can cause you to pay large medical bills.
But you don’t have to take it down, says Caitlin Donovan, health policy expert at the Patient Advocate Foundation. She notes that there are steps you can take to combat these denials, regardless of where you get your health insurance. If you applied for prior authorization for a health service and were refused, you can also appeal this decision.
First, errors can occur at several stages of the claim filing or pre-authorization process, so call your insurer to make sure the decision was not made in error. If not, ask to speak to the reviewer behind the decision and ask for an explanation. Keep notes, because you’ll need this information in writing later, Donovan says.