What Should I Do If My Insurer Denies A Claim?

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For more information about the Affordable Care Act, visit CBSStL.com/ACA.

You pay your health insurance premiums on time. You use doctors and health care facilities listed in your health plan’s network. Yet your insurance company denies your claim. Can you fight this?

Yes, you can. Under the Affordable Care Act (ACA), your insurance company must give you the reason for denial of claims and inform you of your right to appeal their decision. This applies to all health insurance policies issued after March 23, 2010.

A claim denied for administrative reasons often means a clerical error was made by your health care provider when submitting the claim. This usually will be corrected by your provider, but for other claim denials, you will need to take action.

These are three other reasons your claim may be denied:

  • The services you received are not considered medically necessary.
  • The insurance company feels the treatment is ineffective or experimental.
  • The insurer claims you received care you no longer need.

white space What Should I Do If My Insurer Denies A Claim?
You may appeal by requesting an internal review, and if your appeal is not successful, you may seek an external review.

Internal review

You may request your insurance company reconsider your claim. The procedure for initiating an internal review will be outlined in the denial of claim notice. You may need to include a letter from your doctor documenting the medical necessity of the services you need or have already received. You may also need to provide test and treatment results. You have six months to file your appeal.

If you are appealing a denial of coverage for urgent care, care you must receive to protect your life and health, or for services necessary to manage severe pain, your insurance company must give you a decision within 72 hours. For non-urgent care you have not yet received, the insurance company has 30 days to review. For care you have already received, the insurer must make a decision within 60 days.

External review

If your appeal to the insurance company is unsuccessful, you may request that a third party review your claim. You may file a request for an independent review of your claim with your state’s Department of Insurance. If your state does not have an external review process that meets with the ACA standards, you may file an appeal with the U.S. Department of Health and Human Services (HHS). You must file an appeal within 60 days of your insurance company’s final decision. You can request an expedited review for urgent care. If your life and health are in jeopardy, you may wish to file for an external review at the same time you file for an internal one.

Gillian Burdett is a freelance writer covering all things home and living. Her work can be found on Examiner.com.

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