Steps to Appeal a Benefit Claim Denial
- Ask the insurer to explain the reason for the denial in writing.
- Review your policy to see if you should be covered.
- Ask the medical provider to help you get answers from the insurer.
- Take notes about all discussions with the insurer and the health care provider (include dates, names and what was said).
- Keep copies of all medical bills, claims and decisions.
You Have the Right to Appeal
Your health plan (or insurance provider) gives you the right to appeal a claim denial from your insurer. If your health plan denies coverage for a particular cancer treatment, service, test or procedure, an appeal of denied coverage gives you another chance to have the service paid for by the insurance company. The good news is that appealing a denied claim is much easier than you think, and claim denials are often overturned.
When it comes to appealing denied health care coverage, the biggest challenge may be the time and effort it requires to appeal a claim denial. The process can feel overwhelming for patients dealing with cancer treatment and other concerns. If you do not feel well enough to file an appeal, ask a loved one, friend or social worker to help you. Your health care team can also help. Your health and well-being are worth any extra effort that is required.
The most important thing to remember when appealing a claim denial is to not give up, especially if the denial can affect your treatment and health. This may be easier said than done, because dealing with an insurance denial requires patience.
Prepare to Appeal Your Claim Denial
1. Review your insurance plan benefits for how to appeal a claim denial. By law, information about how to appeal a claim denial must be included in your insurance handbook and in any denial letters. Check the table of contents and index in your handbook to find a reference to “appeals”. Start the appeal process with a written request that addresses the specific reason that the claim was denied and the reasons why the denial should be reversed.
If you can’t find the information you need, contact the insurance provider’s customer service department. If you have a self-insured plan, contact a third-party administrator (TPA) to ask about the appeal process. A TPA is an organization that manages group insurance policies for an employer. This organization works with both the employer and the insurer, processing claims and determining eligibility.
You can contact the Employee Benefits Security Administration (EBSA) for help. They work to assure the security of retirement, health and other workplace-related benefits of workers and their families.
2. Clearly understand the reason for denial of claim. Common reasons for denials by insurers include:
- Pre-existing condition: The condition for which you have requested treatment or services is related to a condition that existed before you were covered by this particular insurer or third party administrator (TPA).
- Provider not in insurance network: The doctor or health care professional that provided the treatment or services is not currently in your covered network of providers.
- Lifetime benefit cap: You have already surpassed the lifetime benefit cap for the condition for which you are being treated. Generally, the lifetime cap for certain conditions is $1 million.
- Treatment not FDA-approved: The treatment is considered experimental for your condition.
- Treatment determined as “not medically necessary” or as “unproven” for your condition: The insurer or TPA determined that the treatment you requested is not medically necessary for your condition.
3. Prove medical necessity. This is likely to be most effective way to overturn a claim denial. You and your health care team can work together to build the case for your appeal. Collect letters from your health care provider(s) stating why the treatment is medically necessary for your situation. Include copies of journal articles about medical research studies that show success with that type of treatment.
Levels in the Appeal Process
1. First appeal—to the insurer. Fill out an Appeal Filing Form and write an appeal letter stating why the treatment is medically necessary for your condition. Keep your appeal letter brief and to the point. Use bullet points to make it easy to read. Fax the appeal letter with your documentation, including the letters from your health care team. Then mail a copy of everything by certified mail. Always keep a copy of letters and documentation for your records.
2. Second appeal—to the insurer again. Under the terms of many health plans, you may have to request a second-level review by the insurer. Your second appeal should include more documentation, especially research studies about this type of treatment or service.
3. Third appeal—to an independent review organization (IRO). If the first two appeals didn’t work, you can request a third level appeal to an outside organization, known as an independent review organization (IRO). Depending on your claim, the IRO reviewer might be a doctor or another clinician who is board certified and licensed in the same or similar specialty as your treatment.
Through fax and certified mail, send the IRO a copy of all of the documentation you sent to your insurer. Also send any new documentation you have collected.
Note: Be sure to send in your appeal within the timelines set by your health care plan and your state. For information, contact the customer service department of your insurance provider. If you have a self-insured plan, contact a third-party administrator (TPA) to ask about the process for initiating a third level, external review. The Employee Benefits Security Administration (EBSA) can also assist you.
Who Can Help You File an Appeal?
There is no need to feel alone when preparing to file your claim appeal. Your health care team can provide information to support the appeal. Working together will increase your chances for success. If your health care provider is unsure of whether a treatment is covered, contact the insurer to find out. Ask if there is anything that needs to be done before treatment to make sure it’s covered.
Health care providers can provide you with an Appeal Filing Form to begin the process of appealing the insurance claim denial. Let them know about the Tip Sheet for health care providers by The National Association of Independent Review Organizations (NAIRO).
Others who can help:
- LIVESTRONG Navigation Services provides free, confidential one-on-one support and can help you find assistance with insurance denials/appeals.
- Patient Advocate Foundation (PAF) employs case managers who assist patients through the appeal process. This patient advocacy service helps patients be heard and provides all the necessary information to help convince the insurance company to change their decision and provide coverage for the procedure in question.
- Kaiser Family Foundation (KFF) is a nonprofit, private operating foundation dedicated to providing information and analysis on health care issues to policymakers, the media, the health care community and the general public.
- NAIRO helps consumers better understand their rights under the health care appeal process.
- State Ombudsman Programs are state-funded and run by independent offices that act directly on behalf of a patient who is unable to get needed medical care or other services. Call 2-1-1 to find out if your state offers this program. Childhood Cancer Ombudsman Program (CCOP) provides complaint investigation and resolution for families of children with cancer and adult survivors of childhood cancer. They provide information and research options to families so that they may better exercise their rights in making decisions in the areas of medical treatment, schooling, rehabilitation, employment, and insurance reimbursement and coverage.
- Department of Labor will help you with questions related to appealing a health claim denial involving a self insured plan.
- Attorney or Legal Aid Groups, such as the Cancer Legal Resource Center (CLRC), offer services sometimes for a fee.
- Fast Facts, Health Plan Differences: Fully Insured vs. Self-Insured.
- National Conference of State Legislatures, States Implement Health Reform: Right to Health Insurance Appeals Process.
- Affordable Care Act.
- Employee Retirement Income Security Act (ERISA) Claims and Appeals Procedures.
- Independent Review Organizations.
- Patient's Bill of Rights.
- Patient's Rights FAQ.
Martin, Jacqueline; Nace, Elaine; Grossman Joel; Merlini, Meredith; Hodgkiss, Thomas; and Smith, Gilbert.Do You Know How to Assist in Recovering Costs for Your Patients’ Claim Denials? Benefits Live Magazine.February, 2012. www.nairo.org.
Smith, Gilbert; Martin, Jacqueline; and Hodgkiss, Tom.Know Your Healthcare Appeal Rights: A Q&A on the Health Insurance Appeals Process for Consumers. November 2011. www.nairo.org.
Smith, Gilbert; Senz, Chris. How to Interpret the New Internal and External Appeals Regulations. September, 2010. www.nairo.org.