Fighting a Health Insurance Claim Denial—How to appeal

If you find yourself up against a health insurance claim denial, know that you have options in disputing it. Generally, it’s worth challenging your denied claim. Your insurer may cave in and pay your claim to bypass legal expenses or your opposition could expose a mistake made by your insurer. 

Steps to prevent a dispute:

1. Be sure to read and understand your policy prior to receiving treatment. Take note of treatments and procedures that call for previous approval from your insurer. This approval is important because without it, you may not be covered.

2. Inform your doctor that prior approval is required, if necessary. Your doctor deals with many patients and may not be as familiar with what is covered under your policy as you are.

3. Pay attention to your plan’s network. Some plans do not cover services outside the “network” – certain places where you must go to receive care.  

4. Seek an explanation from your health plan company’s customer service line if you have any questions or don’t understand something in your policy.

5. Keep all records, such as bills and notices from your insurer, so they can be retrieved easily in the future.

What to Do If Your Claim is Denied

The first step is to call your health plan company’s customer service line. Mistaken denials can often be cleared up at this level. If speaking with a representative does not work, you have a few options in resolving the dispute.

Formal Appeals

Refer to your insurance policy to see what paperwork you are required to file. You will be asked to provide a good deal of information, which emphasizes the need to stay organized and keep track of all your records. If your first appeal is denied, odds are there are alternative appeals offered.

– Independent Reviews

If you are unsuccessful in your health plan’s internal appeals process, an independent external review is the next step. Minnesotans can find more information here.

Minnesotans may apply for an independent review with this application

– Arbitration

A final option, if it is offered by your health plan, is arbitration. An independent third party evaluates the dispute and suggests an outcome. The instructions for how to initiate arbitration are usually listed in the contract.  

This is NOT Legal Advice.  Contact Holt Law to determine if representation for a health insurance claim denial is right for you.

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