If Your Plan Doesn’t Pay (Appealing a Reimbursement Decision)
Suppose your insurer won’t pay for a healthcare service, or pays less than you had expected. You have the right to “appeal,” or ask for your case to be formally reconsidered.
Before you file an appeal, talk to your insurer and find out why payment was denied. It might have been a simple mistake, like a coding error. But, the payment may have been denied for some other reason—for instance, because your insurer did not find the treatment medically necessary. In that case, you can appeal.
There are several ways to get instructions on the appeals process. You can call your plan, visit your insurer’s website or read your plan documents or Explanation of Benefits (EOB). You have more than one chance to get your decision reviewed. In most cases, there are three levels of appeals:
- An internal review by your insurer.
- A second-level appeal to the insurer if the first is denied. That appeal will be reviewed by people who weren’t involved in the first appeal.
- If that appeal is denied, a third-level appeal, to an independent outside organization.
Avoid a claim denial by making sure you have the facts about your coverage. Before getting treatment, ask:
- Is it covered? Check your plan documents or call your insurer.
- Do you need preauthorization, or your plan’s approval before you get care? If so, make sure you get it before you visit the provider. Keep a record of the approval number and any supporting documents.
- Are there any limits? For instance, you may only get 12 physical therapy visits each year. If you need more, claims for those extra visits may be denied.
If a claim is denied:
- Talk to your insurer first to make sure the denial was not a simple error.
- File your appeal within the plan’s deadline. Make sure your appeal form or letter is complete and includes any required supporting documents. Your doctor may be able to help.
Keep a record of all communications with your plan. That includes any documents and notes on when you called, to whom you spoke and what was said.
My Claim Was Denied – Now What?
It’s a terrible feeling to open a letter from your insurer and find you owe more money than you thought. Maybe your insurer paid less for a procedure than you expected. Or, maybe they denied a payment entirely. What do you do now?
The first thing to do is talk to your insurer and find out why the claim was denied. It might have been a simple mistake. Maybe your healthcare provider used the wrong code for your treatment when submitting the claim. Or, maybe you got prior authorization like you were supposed to, but your insurer didn’t realize it. If it was just an error, your provider may be able to help you clear up the confusion with your plan.
But, maybe it wasn’t a mistake. The claim may have been denied because, for example, your insurer did not find the treatment medically necessary, considered it experimental, or doesn’t cover the service at all. In that case, you have a legal right to appeal. That means that you can formally ask your plan to reconsider their decision.
(Keep in mind that if your claim is denied because your insurer doesn’t cover that service – say, cosmetic dentistry – your appeal will most likely be denied, too, because that service is simply not part of your plan.)
Your Action Plan: Be Informed
The easiest way to deal with a claim denial is to stop it from happening in the first place. Make sure you understand the services that your plan covers, and the rules that you need to follow.
Before you get treatment, ask:
- Is it covered? Check your plan documents or call your insurer to make sure the service you need is covered by your plan.
- Do you need pre-authorization? If so, make sure you get your authorization first. Keep a record of the approval number and any supporting documents.
- Are there any restrictions? Sometimes, plans will only cover a certain number of specialist visits. For instance, you may only get 12 physical therapy visits each year. If you need more, claims for those extra visits will be denied.
If a claim is denied:
- Talk to your insurer first to make sure it wasn’t an error, like a wrong code or missing information.
- If it wasn’t an error and you decide to appeal, read your plan’s appeal policy carefully. Call and ask questions if there is anything you don’t understand.
- Make sure you file your appeal within the time frame that your plan requires: you don't want your appeal to be denied because it's late. Take note of your plan's appeal deadline.
- Make sure your appeal form or letter is complete and that you include any supporting documents that your plan requires. Your doctor may be able to help you.
- It’s a good idea to document all communications that you have with your plan on a claim you are appealing. This would include records of when, what was said and to whom you have spoken with at your plan, and keeping a copy of everything you have sent and received from your plan.
And most importantly – remember that you are your own best advocate. Speaking up and asking questions up front will help you get the information you need to avoid claim denials and high out-of-pocket costs.