Health Insurance Claim Denied? How to Appeal, Step by Step

Claims are denied for many reasons, and some of them are easy to fix. A billing code may have been entered incorrectly, information may be missing, or the provider may not have been in your plan's network. Other denials come from plan rules: a service needed prior authorization, the insurer decided it was not medically necessary, or the service is excluded or limited under your plan.

Coverage status matters too. If a premium was late or coverage had ended, a claim can be denied for eligibility. Some private health plans also limit or exclude coverage tied to pre-existing conditions, so the plan documents are the place to confirm what applies to you.

Start with the denial notice. It should tell you why the claim was denied and how to appeal. If the reason is unclear, call the insurer and ask which plan provision the decision is based on.

For private-sector employer health plans, federal rules let you ask the plan for copies of the documents, records, and other information relevant to your claim free of charge. Those papers show what information the plan used, so you can respond to it directly.

If the problem is a billing error, your provider can often correct and resubmit the claim. Ask the billing office to confirm when they resubmit it.

An internal appeal asks your insurance company to take a full and fair second look at its decision. Under those federal rules, you must file within 180 days of receiving the denial notice.

Under the federal rules described on HealthCare.gov, an internal appeal must be completed within 30 days if it is for a service you have not received yet, and within 60 days if it is for a service you already received. Urgent situations follow faster timelines.

Use the insurer's appeal form if it has one, or write a letter with your name, claim number, and member ID number. Explain why you disagree, and attach anything that supports your case. Your doctor can also file the appeal for you as your authorized representative.

If the insurer upholds its denial, many plans let you request an external review. An independent reviewer, not your insurance company, looks at the decision. According to HealthCare.gov, you must file a written request within 4 months after you receive the final denial notice.

External review generally covers denials that involve medical judgment, such as medical necessity, denials of treatment the insurer calls experimental or investigational, and cancellation of coverage for alleged false or incomplete application information. Standard reviews are decided within 45 days.

In urgent situations you can ask for an expedited external review, which is decided as soon as possible and no later than 72 hours, and you can ask for it at the same time as your internal appeal. If the external reviewer decides in your favor, your insurer is required by law to accept that decision.

As with internal appeals, short-term, fixed indemnity, government and church plans can follow a different process. Read the appeals section of your plan materials to see which process applies to you.

If you get coverage through a private-sector employer, the U.S. Department of Labor's Employee Benefits Security Administration can answer questions about claims and appeals at 1-866-444-3272 or askebsa.dol.gov. Government and church plans follow different rules.

If your insurance policy was purchased in Florida, the Florida Department of Financial Services, Division of Consumer Services, can help with insurance problems. Call 1-877-MY-FL-CFO (1-877-693-5236), 8 a.m. to 5 p.m. ET, Monday through Friday.

Prime Health Consultants advisors can explain how the claims and appeals process works and guide you through the steps when you need help. Keep in mind that only your insurer, or an external reviewer, can change the decision on a claim.