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How to Appeal a Health Insurance Denial

Written by Eve Becker on May 29, 2012 in Insurance  |   No comments

Dealing with an illness or injury can be upsetting, yet it can add insult to that injury when your health insurance claim is rejected. The insurance company may deny payment for your medical care or it may decide that the treatment your doctor has recommended…

health insurance claim denialDealing with an illness or injury can be upsetting, yet it can add insult to that injury when your health insurance claim is rejected. The insurance company may deny payment for your medical care or it may decide that the treatment your doctor has recommended isn’t medically necessary.

But you don’t need to accept the denial as the final answer, health advocates say. If your insurance claim is denied, you can file an appeal—or several appeals, if necessary—to try to get your insurance company to cover the procedure.

The first step, though, is to avoid a denial in the first place by understanding your health insurance plan, says Erin Moaratty, chief of mission delivery for the nonprofit Patient Advocate Foundation, a free service that helps consumers with health insurance appeals.

“Review and learn the limits and guidelines of your particular policy,” Moaratty says. “Follow the policy to the best of your ability. If you are required to gain a referral, do so to avoid a denial.”

While some denials are clear-cut—for example, if an HMO requires you to remain within its network and you go to a specialist that is out of network—others might be more subjective: An insurance company might deny preauthorization for a procedure that it thinks is a non-standard treatment. It might reject a promising cancer therapy that your doctor has recommended because the therapy is considered experimental. Or it might refuse to pay for a medical service that you’ve already received, deeming that service not medically necessary and putting you on the hook for payment.

Understand the health insurance appeal process

Previously, the health insurance appeal process and external review process differed in each state. Now, the Affordable Care Act, President Obama’s healthcare plan, gives patients rights to appeal and ensures the right to an external review, though only for health plans created or purchased after March 23, 2010.

If internal appeals within the insurance company are denied, consumers have the right to request an external review. It’s worth the hassle. Consumers who appeal outside of their insurance companies win their cases an average of 45 percent of the time, according to the Kaiser Family Foundation.

“When submitting your appeal, keep in mind that the best defense is a good offense,” Moaratty says. When putting together an appeal packet, craft it with as much supporting detail and as many documents as possible. Also, keep a close eye on any deadlines specified by your insurance company.

“A patient’s policy will outline the specific timeline and process for contesting a denied claim. If you do not appeal in a timely manner, you have no recourse,” she says. “There are three levels of appeals, so even if the first appeal does not go in favor of the patient, we encourage [him or her] to continue the process, paying very close attention to the details of why [it was] denied and the timeframe to appeal.”

Come back for next week’s blog with tips for filing a health insurance appeal.

A Chicago-based writer and editor, Eve Becker writes about personal finance, health and other topics. She is a former managing editor of Tribune Media Services.

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