How to File a Health Insurance Appeal
What to Do If Your Insurance Claim Is Denied
Each time an insured person goes to the doctor or emergency room, has a lab test done or experiences a hospital stay, the healthcare provider will file a claim with the insurance company. In a few limited cases, the policyholder may have to file the claim himself or herself. But with the increasing complexity of medical care and electronic health records, most doctors and hospitals are electronically linked with the insurers they do business with. It's easier and more efficient for them to transmit the claim directly.
So in most cases, the patient won't know the insurance company's decision until he or she receives an Explanation of Benefits or EOB. This usually comes in the mail, although many insurers now have secure areas on their websites where customers can check the status of claims online.
The EOB gives the date of service and the medical provider that filed the claim, then explains how much was billed, how much the insurance company paid and how much, if any, the patient is responsible for. This last amount can be a deductible, copayments or coinsurance, or it can be a charge the insurer does not believe it should cover. The EOB should also give some kind of explanation of why a health claim was denied, but it may not give specifics. For example, it might say that a charge was not considered reasonable and customary, but not go into more detail. For that, the patient may have to call the insurance carrier's customer service department, or again, go online.
Once it is established that the insurance carrier has denied a claim - for whatever reason - the policyholder may choose to create an insurance claim appeal. Virtually every health insurance contract includes a right for the policyholder to appeal its decisions, but usually he or she must follow a specific process set out in the contract. Importantly, just calling customer service and verbally complaining may not be considered a formal appeal letter by the insurer.
How to Determine the Process for an Insurance Claim Appeal
So how does an insured person find out the formal process of filing a health insurance complaint or writing a letter of appeal? The answer is surprisingly uncomplicated.
- Check the back of that Explanation of Benefits received in the mail. Most insurers print at least the outline of the appeals process somewhere on that document.
- Patients who prefer to do their business online should check the insurer's website. Again, most insurers will have the instructions there on the web for customers who want to file a complaint or appeal with the company.
- Call the customer service department. Calling in and of itself may not be considered a formal appeal, as some insurers require a formal letter of appeal to be sent in writing, but they are required by law to give their customers a clear explanation of how to do that. Usually the company's customer service department is also required to help customers word and file their appeals if they need that help.
Other Ways to Get Heard When Your Insurance Claim is Denied
Consider appealing directly to the insurance company president's office, especially if it is a smaller, local or regional company. Many insurers have a special assistant in the executive office who is in charge of presidential appeals letters, and the president has a strong interest in making sure complaints get addressed. Most insurance companies list the president's name on their websites along with a mailing address.
Policyholders may also wish to file a complaint with their state's Insurance Commissioner. Again, contact information for the state Department of Insurance can usually be found on the internet. Be sure to CC the insurer's president on the letter sent to the insurance department. Some policyholders have had success in at least getting a response by mentioning that they will consider going to the media if they don't get satisfaction. The local Better Business Bureau is also an option.
How successful this approach will be depends on the nature of the health insurance complaint. Sometimes there is truly nothing the insurance company can do under the terms of the contract. But if an insured individual is getting no response at all from attempts to get in touch with an insurance company representative, these methods may help.
Most insurance companies do business ethically and responsibly. But mistakes do happen, and sometimes the policyholder has legitimate grounds for an insurance appeal or complaint. Knowing how to get in touch with the right people and following the required procedures for a letter of appeal should help make sure the customer's voice is heard.
Call Customer Service for Help in Filing an Appeal
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