A Guide to Fighting Insurance Claim Denials

So you’ve received the gut punch that is a medical bill for a service you expected your insurance to cover…Now what? Check out this guide to the insurance appeals process and learn how to fight health insurance claim denials! (Spoiler alert, you don’t have to fight alone.)

What is a Health Insurance Claim Denial?

A health insurance claim denial is a decision by your insurance provider to not cover the costs for a service you received. Typically you will get a letter in the mail that outlines the details of the denied claim, the reason it was denied, and how much you owe the medical provider as a result.

In other words, a claim denial means you’ll be staring down a surprise bill for that important medical service you received.

How to Start Fighting Health Insurance Claim Denials

The first step in fighting insurance claim denials is to understand why your insurance is refusing to pay. This can involve looking over the denial letter or calling your insurance provider. In order to understand whether or not the claim was wrongfully denied, it might make sense to comb through your health insurance plan documents to clarify the terms of your agreement with your insurance company. Better get out a magnifying glass for all that fine print!

If you decide to fight your insurance denial, the next step in the process may be to file an appeal.

Unsure how go about appealing your insurance company’s decision?

What is a Health Insurance Appeal?

A health insurance appeal challenges the decision your insurer made about who is responsible for paying a claim. Basically, it’s a request for your insurance provider to review the denial in the hopes that they will change their mind.

When to File an Appeal

In most states, you have about six months from your denial to submit an appeal, or four months for external reviews. Even so, when fighting health insurance claim denials it’s best to get going right away to avoid holding up or confusing the process. Filing an appeal is pretty much the go-to first step in fighting insurance denials.

Internal vs. External Appeals

Internal Appeals are requests submitted to your health insurance provider and then looked over by a team within their company.

External Appeals are requests submitted to third-party agencies to review denied claims. This is often done by a local or federal government office.

How to File an Internal Appeal

To file an internal appeal, you’ll need to reach out directly to your insurance provider and ask to start the appeal process. The details of this process vary from company to company, but most likely it will involve filling out paperwork and providing additional evidence that a claim was wrongfully denied.

For example, if you sought mental health counseling but then received an insurance denial because the doctor’s visit was labeled “not medically necessary,” you could ask your counselor to write a letter explaining why the visit was essential to your health. Doctors are good resources in this stage of fighting health insurance claim denials.

How to File an External Appeal

Often you must wait until an internal appeal is unsuccessful before starting the external appeal process. The tough part about filing an external appeal to fight health insurance claim denials is that there may be no clear path forward. Sometimes state-level external appeals may not be available where you live, so you may have to reach out to the federal government for assistance.

How Long Health Insurance Appeals Take

Once you’ve submitted your internal or external appeal, it’s time to play the waiting game. While most companies promise to deliver a decision within 60 days of the appeal, it can take much longer than that. In some cases you can request an expedited appeal.

External appeals tend to come back faster than internal ones, with results in under 45 days. Still, knowing that there’s a chance a hefty bill lies on the other side of those 45 days can make them pretty stressful.

Possible Appeal Outcomes

Depending on different factors (such as the reason for the denial, the terms of your health insurance plan, or the accuracy of the paperwork submitted), you may be successful in getting a denial reversed, or you may not. that very few people actually fight health insurance claim denials, and understandably so—it can be a draining process!

Get Help Fighting Insurance Claim Denials

At least you know that you don’t have to fight insurance denials on your own. Rather than giving in and accepting the bill, ask for help with that daunting appeals process! At aJust solutions, our team of experts are here to fight this battle for you, using an arsenal of know-how and an unmatched attention to detail.