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What should I do if my claim is denied?

To resolve the situation fairly and efficiently, it will help if you have all the paperwork on hand to support your claim.

Tips for Denied Claims

  • When your claim is denied, you will receive an explanation of benefits from your insurance company, which should include a reason for the denial of your claim.
  • If you do not understand the reason for the denial, you may want to call an insurance company representative for a thorough explanation.
  • Make sure to ask for and record the name of the person with whom you are speaking.
  • Understanding what the problem is may help you better organize the papers and documents you need to support your claim.
  • Contact your human resources department if your policy is through your employer. They can often explain why it wasn’t covered or help you work through the system more quickly.
  • You will have a certain period of time in which to appeal the denied claim. State laws vary on the amount of time allowed to appeal, so make sure to check the law in your state or contact your state’s department of insurance.

Double-check that the claim form has been completed correctly. If it has, get the rest of your paperwork in order. Make sure you have a prescription for every piece of equipment you need, even if it does not require a prescription at the pharmacy.

Copies Only

Never send any original documents to your insurance company. Make copies of everything you plan to submit and keep them in a safe place. Send in the copies, and keep the originals. Send all pertinent paperwork by registered mail so you have a record that they have been received.

Tips for Appeal

  • Write to the claims manager of your insurance company, explaining what is wrong. It helps to address the claims manager by name.
  • Point out the items that have been denied payment and ask for a written response to your request.
  • Give your address and phone number, and that of your provider.
  • Also, send your provider a copy of your appeal request for his or her records.
  • State that you will call the insurance company on a certain date if you have not received a response by that time. On that date, call the claims manager and discuss your case. Two to three weeks is a reasonable period of time to wait.

If you work for a company that is self-insured (which many larger employers are), appeal directly to your human resources manager or to the head of the company first.

Dr. Michael Roizen, MD
Internal Medicine

You can fight the system. And you can win. In fact the cards are stacked in your favor. You’ll need persistence, persistence, attention to detail, and more persistence. Many claims are denied initially, but after an appeal or two -- remember what we said about persistence -- insurance companies eventually fold like a lousy poker hand. The help of an experienced insurance guru who can talk the talk and walk the walk makes a difference too.

These tenacious tips will also help your chances of winning:

  • One-size-fits-all coverage is a lot easier for insurance companies. Your goal is to get them to forget about their standard policy and to deal with you as an individual.
  • Learn the technical reason your claim has been refused.  This gives you a specific target to attack.
  • Befriend the customer-service rep who answers the 800 number. He or she is your first potential ally, so try to persuade the rep to help before you launch a formal appeal.
  • Bombard them with facts. You won’t get anywhere with passionate pleas. You need lab data, national trend info, physician letters, and other hard records to show the insurer why it has no basis to deny your claim.
  • Get your case to the insurer’s medical director or staff doc. A doc will usually look at your situation with more sympathetic eyes and give more clout to good patient care versus following standard procedure.
  • If you’re still not satisfied, keep appealing. Remember: persistence, persistence, persistence.

For more help filing an appeal, contact your State Health Insurance Assistance Program (SHIP) for free assistance.

 

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.