How to File a Health Insurance Appeal
In many cases, medical appointments and procedures are followed by an unexpected, unwelcome bill. The appeal process can seem confusing, but these simple steps to appealing a denial of healthcare coverage will help you navigate the process.
- Know the Process: Insurers are required to provide information about the appeals process, so read any extra papers included in the letter of denial. If you can't find it, search for the info on your insurer's website or call the company to request the form be e-mailed to you.
- Study Up: Skim your policy for the section that pertains to your claim. If you can't find it, e-mail, call, or have a virtual chat with your insurer to pinpoint the area in question, says Martin Rosen, cofounder of Health Advocate, an advocacy and assistance group. "Your policy is a contract," he says. The more you know, the better case you can make.
- Gather Your Evidence: Explanations of Benefits (EOBs), bills, medical records—all of it helps you make your case. Put everything together in one place and make copies to send along with your appeal letter.
- Make Your Case in a Letter: Include all the usual things—your policy number, the date and location of the service that's in dispute, and the provider. Cite the portion of your policy that discusses the issue at stake. Attach copies of those EOBs, bills, and medical records—never send the originals—and then cite what the policy says it will cover.
- Have Your Doctor Vouch for You: A letter from your physician explaining why you received the care you did is essential, says Medical Billing Advocates' Palmer. But that's not all your provider can do for you. Ask for an operative report—an explanation of the services performed. "If there were issues during the procedure, if the procedure needed to happen in a certain period of time, or if they needed to do additional procedures once they'd begun, that info will all be on the operative report," she says. "That can increase how much an insurer will pay."
- Ask for an Outside Review: Appeals can go through at least three levels. The first sends your appeal to whoever denied your claim; the second goes to an objective person in the company; the third goes to an independent third party. But you don't have to wait to get to the independent review board. Under the Affordable Care Act, most plans are eligible for such a review. Ask for one in your appeal letter. "They don't volunteer to give you the outside appeals board," Palmer says. "But you have the right to ask. You may get a more impartial hearing this way."