Knowing what to do if your health insurance denies a claim can increase your chances of getting the decision overturned. You have a legal right to appeal the denial decision through either an internal or external appeal.
An internal appeal involves requesting your health insurance company to take a second look at your claim and reconsider its decision. An external appeal involves asking an independent third party to review your claim and decide whether your insurer should pay the claim.
A bad faith insurance lawyer can discuss reasons insurance companies deny claims and guide you through the various steps of appealing a health insurance claim denial. Your attorney will also explain your legal options and give you advice about how to move forward.
What to Do if Your Health Insurance Denies a Claim
Review Your Insurance Contract
Get a copy of the full version of your health insurance policy from your provider. Your bad faith insurance attorney can help you go over the policy to determine if it covers your claim. Your lawyer will also review the exclusions or limitations section to determine what your plan does not cover.
Determine Reasons for the Claim Denial
Your attorney will review the notification, form, or letter you received after your insurance claim denial. He or she will pay special attention to any Explanation of Benefits (EOB) attached. The law requires your insurer to send you a timely and written notification explaining your claim denial reasons. You should receive this notification within:
- 72 hours for emergency treatment
- 15 days if you are requesting advance approval for treatment
- 30 days for treatment already obtained
Your attorney will likely get in touch with your insurer if the claim denial reasons provided are unclear or unjustifiable. If you communicate with the insurer directly, be sure to keep a log of all interactions and communications between you and your insurance company. This record will help you prove that you took all the necessary steps to try to resolve the claim with the insurer before initiating a lawsuit.
Your lawyer can also review the log to determine if the insurance company violated the Unfair Claims Settlement Practice Act (UCSPA). The documented evidence will also help determine if you have valid grounds for an insurance bad faith lawsuit.
Compile Evidence to Show That You Received Medically Necessary Treatment or Service
Call your doctor’s office to determine whether a simple mistake may have contributed to your claim denial. It might be something as simple as entering an incorrect payment code. If so, ask the doctor’s office to make the necessary adjustment and refile the claim.
Request your doctor to confirm that the treatment or service rendered was medically necessary. This confirmation can include your medical records, a detailed letter from your doctor, and medical literature explaining the medical effectiveness of a particular procedure or service.
Understand the Appeal Process
The law allows you to file an appeal if your insurer denies your claim. It also allows you to request a review appeal from your insurance carrier and a third party. Be sure to comply with your policy’s appeal process.
Visit your insurer’s website to obtain information about procedures for filing an appeal and filling out the required paperwork. Also, find out if a deadline for requesting an appeal exists. Feel free to call customer support for more information and clarifications.
Notify your medical provider that you are appealing the denial decision. Request the provider to delay asking for payment until you get a response from your insurer. Also, request your provider to delay sending your bill to a collection agency.
Filing a Denial Appeal
Internal Review Appeal
Requesting an internal review is the first step in appealing if an insurance company denied coverage for a claim. This request involves preparing and sending a detailed appeal letter to your insurer. The letter should include all the facts and arguments required to prove your claim. It should be factual, precise, and courteous.
You must file an internal appeal within 180 days of receiving a notice of your claim denial. Your insurance company must inform you of your right to an internal review. It should also inform you of how to start the appeals process.
A different team of insurance company staff from the one that made the initial decision will review your claim upon receiving your appeal letter. You can ask for an expedited appeal if you need emergency medical treatment or service. Insurance companies usually decide within three days when dealing with an expedited appeal.
Your insurer will notify you of its decision upon completing the internal review. The notification can be in the form of a letter or call. The insurer will pay your claim if it reverses its original decision. Consider other available options if the insurance company affirms the initial decision.
External Review Appeal
Request an external review if you are dissatisfied with the outcome of the internal review. An independent organization will review your claim thoroughly and decide whether your insurer should settle the claim.
The deadline for filing an external appeal with the Office for Consumer Health Assistance (OCHA) in Nevada is four months from when your internal appeal was denied. The deadline is different for some states and health insurance policies.
You may request an external appeal even before the internal one is complete if you are experiencing serious health problems. You may also ask for an expedited review if an urgent decision is required on health grounds. An expedited external review requires the independent organization to decide within 72 hours.
Common Reasons Insurance Companies Deny Claims
A delay, denial, or failure to pay a claim can be frustrating. It may lead to a delay in getting much-needed treatment or medical services. It may also leave you struggling with hefty medical bills, plus calls and threats from collection agencies. The appeals process can also be time-consuming and costly. Knowing common reasons insurance companies deny claims can help you avoid them in the future. It can also streamline the process of appealing the denial decision.
Most insurance companies have timelines for filing claims. Some companies require medical providers to claim within 90 days from the date they rendered service. Others give them only 30 days. Filing past the deadline may result in a rejection.
Request evidence of the submission date from your doctor or medical facility’s billing personnel. Ask your medical provider to resolve the issue with the insurer if late filing got your insurance claim denied. Continue following up with your provider until the matter is resolved, and the claim is paid.
The Claim Has Incomplete, Missing, or Inaccurate Information
Most health insurance claims get rejected or denied due to medical billing and coding mistakes. The paperwork may have incomplete, missing, or inaccurate information. Go over your EOB and billing statement to try to identify the mistake. Enlist the services of a claims assistance professional if you cannot spot the error on your own.
Contact your provider if you identify any billing or coding mistakes. He or she should make the necessary adjustment and resubmit your claim immediately.
Failing to Provide Requested Information
Your insurance company may reject or deny your claim if you fail to provide the requested information. Do not ignore any communication from the company. Instead, seek clarification from it if you are unsure of the steps to take.
Share with your insurer your reason for failing to respond. The insurer may allow you to provide the requested information past the deadline and settle the claim. Review your policy to see if it has any clause that allows your insurer to deny your claim if you fail to deliver the requested information on time.
Lack of Medical Necessity
Most health plans have unique procedures for determining the medical necessity of a treatment or healthcare service. Your claim may get denied or rejected if the treatment or service sought or received is considered medically unnecessary.
You need to demonstrate that the treatment sought or obtained is necessary. This demonstration might involve presenting your medical records and a detailed letter explaining the significance of a specific treatment or service. You can also cite reports and articles from reputable journals discussing the effectiveness of a particular treatment for your medical condition.
Lack of Pre-Authorization of a Specific Treatment or Service
Pre-authorization is necessary for some medical services and diagnostic tests like MRIs. Your medical provider should request prior approval for such services and procedures. Some providers require you to obtain prior authorization before providing certain services. Others offer those services even without pre-authorization. Request your provider to compose a letter justifying the medical necessity of the service rendered. In explaining what to do if your health insurance denies a claim, an attorney will likely advise that you submit this letter together with your appeal.