Steps to Appeal a Health Insurance Claim Denial

When you’re recovering from an illness or injury, having a health insurance claim denied can be frustrating and stressful. Take a deep breath, then read this step-by-step guide on how to appeal a health insurance claim denial.

Step 1: Find Out Why Your Claim Was Denied

Before you can submit an appeal, you need to understand why your claim was denied. Review the denial letter from your insurance plan to find out more. Your claim may be denied if:

  • There was an error when the claim was filed, such as missing or incomplete information in the claim documents
  • Your plan does not cover the service you’re claiming
  • The service was deemed not medically necessary
  • Your plan doesn’t cover the out-of-network provider
  • You have reached the coverage maximum of your plan

The claim denial notice should include detailed information about the denied claim, how long you have to appeal the decision, and how you can appeal the decision.

Step 2: Call Your Insurance Provider

You can start the appeal process by calling your insurance provider. Ask for more details about the denial and review your appeal options. Your insurance agent can walk you through the appeals process to help get you started. Each insurance company has a specific appeals process, and you’ll need to follow all the steps carefully. Make sure you find out what forms you need to submit, and how long you have to appeal the decision.

Step 3: Call Your Doctor’s Office

Sometimes a claim may be denied because your service provider left out important information on the claim form or didn’t use the right code when submitting a claim. You can ask your doctor to resubmit the claim and correct the error.

If your claim was denied for another reason, let your doctor know that you’re appealing a claim. You can ask your doctor to write a letter explaining that the service was medically necessary, or provide other supporting documents. You can also ask your provider to hold your bills until the appeal process is completed so you won't need to stress about paying a large healthcare bill.

Step 4: Collect the Right Paperwork

As you prepare to appeal a claim denial, gather all the paperwork related to your claim, the service provided, and the denial. This should include:

  • The claim denial letter from your insurance provider
  • Original bills and documents related to the service
  • Notes and dates from phone calls with your insurance company or your doctor’s office
  • Any other documents you plan to submit to your provider, such as supporting information from your doctor
  • Your policy documents, including your Evidence of Coverage or Summary of Benefits

Step 5: Submit an Internal Appeal

Now you’re ready to submit an internal appeal directly to your insurance company, asking them to reconsider your case and reverse the decision to deny coverage. You can explain the error and even ask for a full review. You'll need to fill out all required forms and write an appeal letter. The letter should include:

  • What service was denied and why
  • Your claim number
  • Why your claim should be paid, with supporting evidence from your plan policy documents
  • Overview of your health condition and details about why the service is medically necessary
  • Supporting evidence, such as medical records or a letter from your doctor

You may feel frustrated and upset, but you should write a straightforward letter that gets right to the point. Keep your emotions out of the letter and clearly explain why you should get coverage.

Step 6: Wait For An Answer

Your insurance provider is required to make a decision quickly. If you’re appealing coverage for a treatment you have not received, they must make a decision within 30 days. If you’ve already received treatment, they must reply within 60 days. If you’re appealing a claim denial for urgent care, your insurance company must decide within 72 hours.

Step 7: Submit an External Review

If your internal appeal is rejected, you can submit your case to an independent third party for an external review. Someone who doesn’t work for your insurance company will do a full review and give you a final answer. You can find more information about your external review options in your Explanation of Benefits (EOB), along with contact details for the external reviewer.

Review Your Plan Coverage

To prevent claims denials in the future, explore your plan and coverage options. Ask your insurance provider about any coverage limitations and get preauthorization for services that might not be covered. You can also contact CareFirst for more tips on accessing affordable care.