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How Can You Appeal Against Denied Health Insurance Claims?

By Laxita Gautam
  | Published: 07 May 2021

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Fighting your way through seemingly never-ending ordeals that diseases often are can be very tiring and may take a toll on you emotionally, mentally, physically, and financially. While the first three can be rebuilt by rehabilitation therapy, most of us rely on health insurance coverage to cover the financial toll. It can be extra hard if your health insurance claim is rejected for any unforeseen reason in a situation like this. While there can be a valid reason for the claim to have been denied or rejected, it also often happens due to petty mistakes. It is important that you know how to appeal against health insurance denials and rejections in order to get through this struggle smoothly.

Denied Insurance Claims vs Rejected Insurance Claim

You need to know all about the terminology before you set on the journey to resubmit your denied or rejected the claim. There is a fine line between rejected claims and claims that have been denied. Denied claims have been entered into the system of the insurance company, processed, and deemed as an unpayable claim. Rejected claims are the ones that were filed by the policyholders, but not entered in the system of the insurance company because there was an error in the application.

Denied claims often come back with an explanation from the payer i.e., the insurance company mentions the reasons for which your claim has been denied. This particular explanation can be either Explanation of Benefits or Electronic Remittance Advice. Depending on the reason a certain claim was denied, the policyholder can choose to take the required action for resubmission of the claim. A denied claim requires to be submitted accompanied with a well-constructed appeal explaining that this particular claim is being appealed for the denial received earlier. If not done so, the resubmitted claim will probably be seen as a clone or duplicate of the previously sent claim and will end up getting denied the same way.

Rejected claims are often a result of EDI rejection in case of electronic submission or online submission. The reasons for rejection of a claim can be as simple as a missing number or alphabet in the issuance ID of the policyholder or other simple spelling errors. A simple rectification of the committed error can make the claim eligible for resubmission. There is often no need for an appeal in case of a rejected claim.

What are the Reasons for a Claim to be Denied?

There are a few reasons for the insurance company to process a submitted claim as denied. Knowing these reasons is important because only then you will be able to figure out whether the denied claim is eligible for an appeal and if yes then what is the way to go along with the process. Following are the top reasons for a health insurance claim to get denied in the first place:

  • The information submitted regarding the medical bills was incorrect.
  • There are clerical errors in the application submitted or necessary information is missing.
  • The documents supporting the medical billing and the claim were not complete.
  • The insurance plan does not cover the services and procedure that you have made a claim for.
  • The coverage limit of your health insurance plan has been exhausted already.
  • The medicines and drugs that you have claimed are non-formulary and a cost-effective generic alternative exists for them.
  • The healthcare providers that you have used are not covered by the in-network list of your insurance plan.
  • The treatment that you are applying for has been classified as “not medically necessary” or “experimental” for your condition.

How to File Appeal Against Denied Health Insurance Claims?

As soon as you have determined the reason for the denial of your claim, it is time to determine the approach that you need to take in order to fight the denial. The reason for denial will be explained in the letter that you will receive from your insurance company. If the reason is as simple as lack of documentation or medical billing, all you need to do is gather the required documents from the list and get the billing from your doctor rechecked and redone.

If the reason for the denial is that the services and treatment claimed a not medically necessary for your condition in general, you will have to get written proof from your doctor or any other doctor stating that the procedure was indeed medically necessary. Reasons for that can be anything including that being the only procedure that would have worked, failure of the past tried the procedure, the procedure was a cheaper option as compared to others available for your condition, etc.

It is not necessary that every denial can be fought back with a rebuttal like claiming against an expired policy. But there are plenty of cases when technicalities and general terms and conditions are in a state to be challenged by the policyholders. If you are unsure about the denial and the way to proceed with the resubmission process, you can always call your insurance provider and get a better understanding of the situation.

Know the Appeal Process for your Insurance Company

It won’t be a surprising thing if you find out that the appeal process of your company is slightly different from that of other companies because is mostly the case. Knowing the proper steps involved in the appeal process of your insurance company beforehand is extremely important because that is the only way you can make sure that your appeal does not get lost in the middle of the line somewhere. There are few simple things that you can do to find out about the process:

Read the terms and conditions of your plan laid out in fine font.

  • Check the website of your plan provider. There are often sections dedicated to the explanation.
  • Call customer support.  When nothing seems to work, you can simply seek assistance from the experts.
  • Be thorough about everything – get to know the steps, proper documentation needed, and the deadlines, if there are any.

Appeal Letter for Fighting Claim Denials – What Should it Include?

An appeal letter is necessary to be included in your claim resubmission application after the denial of the first attempt. It not only facilitates communication but also makes sure that the appeal process moves along smoothly. Make sure that you have prepared a well-structured letter for your denial appeal by adding the following things:

Opening Statement of the Letter: Mention the purpose of the letter i.e., denial of a health insurance claim in a clear, easy-to-understand manner. Also mention the services that were denied in the claim by the insurance provider and the reason for the denial as explained in the letter you received from the provider. Add that you would like to appeal against the said decision of denial from the provider.

History of Health Problems/Medical Conditions: In the lieu of explaining the treatment or medicines or medical support that was denied in the claim, explain the reasons for which you required them. You will have to explain why the procedure/drugs were medically necessary and your health condition as well. Also, explain the treatments that you have already tried but did not work, if any.

Doctor’s Word as Supporting Info: A note, letter, or any form of written confirmation from your doctor is going to help you a lot in the claim process. Make sure that letter has a stamp from a recognized medical hospital or institution and represents that the services you are applying the claim for as a part of the treatment plan for your condition.

The Final Word

Keeping your options flexible will always be helpful in this condition. There are forums that can help you if the appeal process does not seem fair and require an impartial middleman to intervene. Make sure that you approach them if things come to it. On top of everything, be extra careful with details when you are in the process of filing an appeal and resubmission of a claim. The process is going to be time-consuming and expensive too so there should be no room for another denial due to clerical errors, missing documents, etc. If you are through with the research and the work, the appeal against denied health insurance will go smoothly.

Laxita Gautam
Laxita Gautam21 Posts

Senior Content Writer | She functions on classic British fiction, Japanese manga, and strong americanos. Laxita is tailor-made to create engaging, interactive pieces that offer simplified insights into complex subjects.