If your health insurer denies your claim or cancels your coverage, you have the right to appeal that decision. A claim is a request for coverage. You or your health care provider file a claim to get reimbursement from the insurer for the costs of treatment or services.
If your insurer denies your claim, they are required to explain why they’ve denied your claim or ended your coverage, and how to go through their appeal process.
Common reasons why insurers deny claims
Health insurers issue denials for the range of reasons. Below are some of the most common:
- The benefit isn’t offered under your health plan.
- Your medical problem started before you enrolled in your current plan.
- You received health services from a health provider or facility that isn’t in your plan’s approved network.
- The requested service or treatment is considered “not medically necessary.”
- The requested service or treatment is an “experimental” or “investigative” treatment.
- You’re no longer enrolled or eligible to be enrolled in the health plan.
- The insurance company believes false or incomplete information was given when you applied for coverage.
There are two types of appeals: internal and external.
How to file an internal appeal
Prior to filing your appeal
Gather together copies (keep the originals in your files) of any information related to your claim. This includes:
- Explanation of Benefits (EOB) statements showing what payment or services were denied
- Any documents with additional information sent to the insurance company (like a letter or other information from your doctor)
- Notes and dates from any phone conversations you have with your insurance company or your doctor that relate to your appeal. Include the day, time, name, and title of the person you talked to and details about the conversation.
If your health care provider files the appeal, also send a copy of the letter or form you may have signed allowing the provider to act on your behalf.
Filing the appeal
There are typically two steps in the internal appeals process:
- Complete all forms required by your health insurer. Or you can write to your insurer with your name, claim number, and health insurance ID number.
- Submit the additional information (listed above) with your forms or letter.
You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied.
How long does an internal appeal take?
If you are seeking prior authorization for an eczema treatment and your insurer denies the claim, they must notify you within 15 days of the reasons for the denial.
If you are seeking reimbursement medical services you already received and your insurer denies the claim, they must notify you within 30 days of the reasons for the denial.
If you are seeking reimbursement or prior authorization for urgent care services and your insurer denies the claim, they must notify you within 72 hours of the reasons for the denial.
In urgent situations, you can request an external review even if you haven’t completed all of the health plan’s internal appeals processes. You can file an expedited appeal if the timeline for the standard appeal process would seriously harm your life or health. You may file an internal appeal and an external review request at the same time.
For a more detailed explanation of the appeals process, please visit A Patient’s Guide to Navigating the Insurance Appeals Process.
How to file an external review?
If your insurance company still denies your claim, you can file for an external review. External reviews are done by state governments and in the absence of state services, the Department of Health and Human Services of the federal government.
What types of denials can go to external review?
Any denial where you or your provider disagree with the insurer
Any denial where the insurer deems the treatment experimental or investigational
Cancellation of coverage based on your insurer’s claim that you gave false or incomplete information when you applied for coverage
Prior to filing for an external review
Look at the information on your Explanation of Benefits (EOB) or on the final denial of the internal appeal by your health plan. It’ll give you the contact information for the organization that will handle your external review.
If you can’t find your EOB or final denial, go to this state list maintained by the National Association of Insurance Commissioners to find your state’s external review information.
By law, insurance companies in all states must participate in an external review process.
You may appoint someone (like your doctor or another medical professional) familiar with your medical situation to file an external review on your behalf.
Filing an external review
Within 60 days of the date your insurer mailed you a final decision on the internal appeal, follow the directions for the filing process for your state to submit a request for an external review.
No later than 60 days after the request was filed, the external reviewer issues a final decision to either:
- Uphold your insurer’s decision to deny the claim; or,
- Decide in your favor and the insurer is required by law to accept the external reviewer’s decision.
For a more information on the appeals process, please read A Patient’s Guide to Navigating the Insurance Appeals Process.
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