If Your Health Insurance Claim Is Denied

Sometimes insurers will deny claims or say they won’t pay for a test, procedure, or service that your health care provider orders. Know that it is your right to be able to appeal many health insurance denials.

There are two types of appeal processes

• Internal reviews are when you ask an insurance plan to change their decision about a pre-approval request or paying a claim.
• External reviews can be requested if the insurance plan still doesn’t want to pay after an internal review. These are done by independent organizations outside of your insurance plan.

Before filing an appeal

If an insurer denies a claim, they must tell you that you have a right to appeal. They also must let you know how you can appeal. Make sure to find out how long you have to file an appeal.

If you ask for it, the insurer must explain the reasons for the denial. You can also ask for more information from a customer service representative or case manager at your insurance company. It can be helpful to develop a relationship with a case manager early on in case you need them in the future.

You might also be able to re-submit the claim with a copy of the denial letter and your doctor's explanation. Include any other written information that support using the test or treatment that has been denied. Sometimes the claim will only need to be “coded” differently.

Internal appeals

If getting help from your health care team or insurance plan doesn’t work, you may need to submit an internal appeal.

• Request a  denial response in writing l. (Keep the originals of all the letters you get. Your cancer care team may be able to help you make copies if you need them.)
• Keep a record of dates, names, and calls you have about the denial.
• Formally appeal the denial in writing, explaining why you think the claim should be paid. Your cancer care team (doctor, nurse, social worker) may be able to help with this.
• Be persistent and don’t back down when trying to resolve the matter.
• Get help from the consumer services division of your state insurance department or commission.
• Find out if you live in one of the US states that also has a special Consumer Assistance Program (CAP) that can help you file an appeal.

External reviews

If your internal appeal is denied, you can ask for an external review.  External reviews are done most often for care that may be a medical necessity or denials of other decisions based on clinical judgment.

Check with your insurance company about the external review process. For an urgent health situation, you may be able to ask for an external review at the same time you ask for an internal one.

You can also find more information about external reviews and the laws that apply to them on Centers for Medicare & Medicaid Services website.

If you can't resolve your problem directly with the health plan

If your claim is still denied after internal and external appeals, ask the health care provider if the cost of the bill can be reduced. Many providers are willing to reduce bills to get paid faster.

If none of these steps work, you might have to take your appeal to a government body.

It helps to know who regulates a health plan. You can talk to the government group that regulates the health plan to find out if they can offer more information or extra help.

• Private group plans (or fully insured plans) purchased by employers as a benefit for employees are usually overseen by the state’s insurance commissioner or department of insurance. You can find your state’s insurance department by contacting the National Association of InsuranceCommissioners.
• Self-funded plans (or self-insured plans) are health plans that employers or unions create just for their employees and families. They are overseen by the US Department of Labor’s Employee Benefits Security Administration. Ask your employer if you’re not sure whether your employer is self-funded.
• Individual plans sold through the health insurance marketplaces are regulated by a marketplace board in each state. This state board oversees the marketplace and the plans sold by it.
• Managed care plans are regulated by several state and federal agencies. Your state insurance commissioner or department of insurance can provide specific information about a plan.
• Medigap policies (Medicare Supplement Insurance policies) are overseen by federal agencies, as well as some state laws. Contact the Centers for Medicare and Medicaid Services (CMS) and/or your state department of insurance for information.
• Medicaid and CHIP are joint programs that are controlled by your state health department and the federal Centers for Medicare and Medicaid Services.
• Medicare is run by the federal Centers for Medicare and Medicaid Services.
• TRICARE is overseen by the US Department of Defense.
• The Veteran’s Health Administration is regulated by the US Department of Veteran’s Affairs.
• Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is run by the VA Chief Business Office Purchased Care.

Need more information?

National Association of Insurance Commissioners
Toll-free Number: 816-783-8500
Email: help@naic.org
Website: content.naic.org/state-insurance-departments

Offers contact information for your state insurance commission. You can contact your state insurance commission for insurance information specific to your state, or report problems with your insurance company.

Medicare Rights Center (for those with Medicare)
Toll-free number: 1-800-333-4114
Website:  www.medicarerights.org

This service can help you understand your rights and benefits, work through the Medicare system, and get quality care. They can also help you apply for programs that help reduce your costs for prescription drugs and medical care, and guide you through the appeals process if your Medicare prescription drug plan denies coverage for drugs you need.

Patient Advocate Foundation (PAF)
Toll-free number: 1- 800-532-5274
Website: www.patientadvocate.org

Works with the patient and insurer, employer and/or creditors to resolve insurance, job retention and/or debt problems related to their diagnosis, with help from case managers, doctors, and attorneys. Typically for cancer patients in treatment or less than 6 months out of treatment.