Appealing Rejected Health Insurance Claims

When an insurance company fails to pay a medical claim, there are steps you can take to appeal the health plan’s decision. Under the Affordable Care Act, the law gives you the right to disagree by filing an appeal.

If you appeal, the insurance company must review your claim and render a decision. A personal injury lawyer can help you understand the claim process and aid you in navigating the steps in the appeal process if you decide to go that route.

Initial Denial of Health Insurance Claim

When a health plan denies payment of your insurance claim for medical services, you have the right to know why your claim has been denied. The insurer must inform you of the reason in writing. Generally, health plans deny payment of a service if the service billed is not considered medically necessary, the treatment has not been proven effective, or the treatment is viewed as experimental. Other reasons for denial include ineligibility for a particular benefit or a service that is coded or billed incorrectly.

Right to Appeal

Provisions of your health insurance contract should state your right to appeal the denial. You also have the right to a review by an independent third party if your appeal is denied. Your insurance company must explain to you how to go about the appeal process. Since there are specific time frames for appealing a health insurance claim, the health plan must state the deadline for filing your appeal. Before filing an appeal, check your health plan contract for exclusions as not all health services may be covered.

Although states and health insurance plans vary in the number of steps in the appeal process, for many, the first attempt to challenge your insurance company’s decision is a request for reconsideration. Other insurers move directly to the internal review process.

Internal Review

While some health plans give you more time to file an appeal, usually, you must file an appeal request in writing within 60 days of receiving notice that your insurance claim was rejected. This step in the process involves the insurer conducting a review of its decision, which can take up to 60 days. An internal review is handled by individuals within the insurance company—often a medical director—who played no part in rejecting your insurance claim the first time.

When you file your initial appeal, you may include additional documentation that supports the details of the claim. In compiling this information, keep in mind that reviewers need to see how a service or treatment fits the health plan’s guidelines.

Documentation can include test results and clinic notes written by your doctors describing the treatment you received and how you responded to it. You can also include a personal statement explaining why you needed that particular medical service.

Request for External Review

If your appeal is denied, you have the right to an external review process. Because the process is often confusing, an attorney who understands how the health insurance system works can help you prepare for an independent external review.

The organization responsible for conducting the external review includes expert medical consultants. These consultants are health care professionals who have knowledge of the medical condition for which you were treated. Reviewers must also have experience with the medical procedure or treatment under dispute.

The federal minimum requirements for an external review process mandate that the medical service for which you are requesting payment by your health plan must meet certain criteria. Primarily, the service must be a benefit covered by the health plan and your benefit for that category of medical services must not have exceeded its limit.

Some states have their own external review processes. In that case, you may have more consumer protection benefits than what the health care law provides. That’s good news since despite the complexity of the appeal process, an external review may get your claim paid. External reviewers normally take 60 days or fewer to reach a decision.

Notification of Final Outcome

If your case goes to the next step for review, your insurance plan must provide the reviewing organization with any medical records, reports from health care professionals, and recommendations from treating physicians that the plan used to deny your claim. Reviewers consider whether this information provides medical or scientific evidence of a generally accepted standard of care.

This phase of the appeal process can take time, and the external review may uphold the insurer’s decision not to pay the claim or may overturn only part of the health plan’s decision. However, if the external review sides with you, the insurance company must pay the claim. You will be notified of the decision of the external review in writing.

If you need help fighting a large denied health insurance claim, the skilled team of personal injury attorneys at Gelman Gelman Wiskow & McCarthy LLC have the experience to litigate your claim.