What to do when your health insurance claim is denied?
If your health insurance claim is denied, you should begin by reading your explanation of benefits and health care plan to determine whether or not you believe the service should have been covered. If you think it should have, then call your health plan’s customer service line. It is not uncommon for mistaken denials to be resolved with a phone call, but be sure to take notes on all phone conversations, including the date and time of the call, the names of the people you talk to and what was discussed.
If a customer service representative does not reverse your claim denial, you will likely have to escalate to a formal written appeal. The appeals process is very time sensitive, so make sure you comply with all deadlines, which will likely be included on your denial notice and explanation of benefits.
Furthermore, your insurance policy will describe the records your health plan requires to properly file your appeal. You should expect to provide a great deal of documentation, including copies of bills, your healthcare provider’s name, address and phone number, and your physician’s statement about why your treatment was or will be necessary. This process can be complicated and it is often challenging to persuade an insurance company that a certain procedure, service or durable medical equipment is covered, so be sure to fully understand your policy, the particular medical service you received and why it was covered. Depending on the costs involved, you may wish to speak with an attorney to assist your preparation of the appeal.
Many health plans have several steps in the appeal process. If your initial appeal is denied, you most likely will have additional appeals available. The entire appeal process should be outlined in the benefits booklet you received from your health plan. Again, make sure you comply with deadlines. Failure to do so can result in a procedural denial of your claim and might bar you from bringing any further action for coverage.
In many states, including Virginia, you can ask your state insurance commissioner’s office to conduct an independent review of your dispute. Generally, this step is taken after you go through your health plan’s internal appeals process first, but often times it is a good idea to reach out to government agencies to assist in facilitating a fair determination of your insurance claim denial.
Be Prepared: The more documentation you have, including records relating to the care received and the basis for coverage, the more likely you are to win your claims denial appeal. Create a comprehensive record by gathering:
- your health insurance policy
- copies of denial letters from your health plan
- copies of any correspondence between you and your health plan, or between your health care provider (such as your doctor, hospital, or lab) and your health plan
- detailed notes of conversations with your health plan
- copies of correspondence with your state insurance department
To speak with an attorney about navigating the appeals process or filing a civil action to enforce a health care plan, click here.