How to Appeal for a Health Insurance Claim Denial.

By: Taylor


Anyone could face a denied insurance claim while availing a medical service. There may be number of reasons for denial of a claim. Many of them can be appealed against. One can get legal help for disputing the claim denial. The best way to prevent a health insurance claim denial is to be aware of each and every clause in the health insurance plan, but even then sometimes health insurance companies deny claims on wrong basis. It is worthy to fight for denied claim as sometimes there may be out of court settlement too or the claimant can get compensation for denied claim.

Rights against Denied Claims

Claims could be denied for many reasons including billing errors, missing information, eligibility issues or any other such reasons. Insured individuals have right to both an internal and external appeal. After implementation of The Affordable Care Act people got the right of an independent third party review too.

How to Appeal a Denial of Coverage

If a health insurance claim has been denied, it is better to follow a step by step process.

Firstly the claimant should find out the reason of denial and whether it is justified. If the denial is not right he should proceed further.

Then he should review his policy and explanation of benefits. He should be aware of all the deadlines and procedures. Keeping detailed records of all the contacts with insurer helps a lot. After arranging all the documents, he should review the appeal process and present his case to the company and ask for an internal review. He may ask for documents from his doctor or employer to support the case.

If the insurance company’s internal appeal process did not work he can go for external appeal. In case of internal appeal not being granted he can file a claim with state’s insurance department. The claimant can also go for an independent third party review.

Before filing an internal appeal the claimant should be organized. He would need to collect following documents before an appeal :-

Health insurance policy
Insurance plan or group number and/or Social Security number
Explanation of Benefits (EOB) forms
Copy of the health plan booklet describing coverage related to treatment
Copies of the medical records
Copies of denial letters from health plan
Copies of any correspondence between the claimant and insurance company
Bills for the services in question
Copies of any correspondence between claimant and health care provider and insurer
Details of conversations with insurer
Copies of correspondence with state insurance department

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