Guide to Appealing Health Insurance Claim Denials

So, your health insurance company has denied your claim. You can—and should—appeal their decision, and here’s how to do it:

Determine the Reason for Denial

First, you must determine the reason for the denial. The insurance company is required by federal law to provide you with a reason for the denial, which is most likely contained in your denial letter. But sometimes insurance companies don’t follow the law and fail to provide an adequate explanation for the denial, in which case you’ll need to call the insurance company to get that information.

The denial letter should also contain the insurance company’s contact information and instructions on how to submit an appeal. Be very careful to meet the deadline for submitting an appeal, which is typically 180 days from the date of denial.

How to Respond

The way you respond depends on the reason for the denial, and there are many reasons insurance companies deny claims, such as:

Denial Reason #1: Clerical or Coding Error

If the denial is based on improper coding or some other clerical error on the part of the doctor or other billing provider, then you’ll need to call the provider’s office and ask them to re-submit a corrected bill to the insurer. Most providers’ billing office staff are very helpful. If they aren’t, and they give you a hard time about re-submitting the bill, you might gently remind them that Virginia law (Va. Code § 8.01-27.5(B)) requires all in-network providers to submit proper claims on a patients’ behalf as long as the patient has given the provider his or her valid insurance information.

Denial Reason #2: Excluded Services

If the denial is based on the insurance company’s determination that the services at issue are not covered under your insurance plan, get a full copy of your health insurance policy, which must provide a list of excluded services.

If the claim involves payment for a medication, make sure the drug at issue is not included in the plan’s formulary or drug list, which lists the prescription drugs your health plan covers. Often, generic drugs are covered in a formulary whereas their brand-name equivalents are not. In that case, you might want to check with your provider to see if a generic equivalent is available. If it’s not, see Denial Reason #3 below.

Denial Reason #3: Not Medically Necessary

If the denial is based on the insurance company’s determination that the care at issue is not medically necessary, begin by working with your provider’s staff to compile evidence demonstrating that the care you received (or will receive) is medically necessary. You might even ask your provider to write a letter to the insurance company on your behalf. Whether you or your provider compiles and explains the evidence, be sure to include:

  • A full history of your relevant health problem(s).
  • Any treatments or therapies you’ve tried and the deterioration in your condition following those treatments.
  • Any supporting medical literature, such as peer-reviewed journal articles, such as JAMA or NEJM, or treatment guidelines from esteemed medical organizations, such as the American Medical Association.

Denial Reason #4: Out-of-Network Provider

If the denial is based on the insurance company’s determination that the care at issue was delivered by an out-of-network provider, you may be able to successfully appeal a denial if you demonstrate that there were no in-network providers in your area capable of providing the care you received. In your appeal letter, also include documentation (such as a physician’s letter) showing that the service you received was medically necessary for your condition.

Denial Reason #5: Failure to Adhere to Step Treatment Requirements

If the denial is based on the insurance company’s determination that the care at issue did not adhere to step-treatment requirements—policies which require a patient to try less-expensive drugs or treatments before “stepping up” to pricier drugs and treatments—then check your health plan to determine what step-therapy measures, if any, must be attempted before the care you received can be covered under your health plan.

If you have fulfilled the requirements, provide documentation of your treatment course in your appeal letter. If you have not fulfilled the requirements, ask your provider to write a letter explaining why it was medically necessary or appropriate to circumvent the insurer’s preferred treatment in favor of a more expensive course of treatment.

Denial Reason #6: Benefit Limits Exceeded

If the denial is based on the insurance company’s determination that the care at issue exceeded your benefit limits, first determine what benefit limits your plan actually has. Under the Affordable Care Act (“Obamacare”), as of 2014, health plans cannot put an annual dollar limit or lifetime dollar limit on spending for health care services that are considered “essential.”

However, they may impose other limits, such as how many times a person can receive a certain type of care. For example, a plan may cover only 20 sessions of physical therapy for a single condition or injury per year. In your appeal, include a letter from your provider to your insurance company stating why the services they provided are essential, and should not be subject to benefit limits.

Denial Reason #7: No Pre-Authorization Was Submitted

If the denial is based on the insurance company’s determination that no pre-authorization was submitted for the care at issue, contact your provider to determine whether or not they obtained prior authorization from your health plan for the services you received. If your provider did receive authorization, they should be able to provide you with an authorization number, which you should include in your appeal letter, along with a statement from your provider about why the services you received were medically necessary.

If pre-authorization was not obtained because you received care on an emergency basis, then state in your appeal letter that pre-authorization was impossible to obtain on those grounds. If pre-authorization was not submitted by your provider due to an error on your provider’s part, and your provider is in-network with your health plan, you might ask your insurer to overturn their decision on the grounds that you should not be held liable for your provider’s failure to take appropriate action.

It is important to note that only “grandfathered” health plans are exempt from annual and lifetime dollar limits, and such plans are exceedingly rare. “Grandfathered” plans must have been purchased by an individual, not through their employer, prior to March 23, 2010.

Denial Reason #8: Expedited Appeals

Appeals of health insurance claim denials take time, but if your situation is medically urgent, you may be entitled to an expedited appeal. A claim is considered medically urgent if:

  • You are currently receiving the treatment at issue and your medical provider believes a delay in treatment could seriously jeopardize your life or overall health, affect your ability to regain maximum function, or subject you to severe and intolerable pain.
  • Your claim is related to an admission or continued inpatient hospital stay and you have not yet been discharged.

In these cases, the insurer must respond to your expedited appeal request within 24 to 72 hours. The decision may be delivered verbally but must be followed by written documentation within the following 72 hours. You are not entitled to an expedited appeal if:

  • You have already received the treatment at issue.
  • Your situation is not considered urgent by a medical provider with knowledge of your medical condition or the medical director of your insurance plan.

Keeping Records Matters

In all of the steps listed above, make sure you keep good records, including all letters received, and notes recording the names of all insurance representatives and/or healthcare provider’s staff members you speak with, as well as the date, time, and details of all such communications.

Contact Norton Health Law Today

If you have exhausted all levels of the administrative appeals process without a satisfactory result, our team at Norton Health Law can help you fight your insurer’s decision in court. We are committed to improving the quality and length of our client’s lives by advocating for their healthcare rights.

Give us a call at (434) 216-4020 to request a free initial consultation to discuss your case and how we can assist you.