How to Appeal a Denied Medical Claim

Since the COVID-19 pandemic began, the number of health insurance claim denials in the US has risen by 11%. Even with denied medical claims more common than ever, surprisingly few of them are resubmitted or appealed.

Tempted to pay the bill for your denied medical claim rather than take on the appeal process? Save yourself the money and keep reading to learn how to correctly appeal a denied claim.

Why You Should Appeal a Denied Claim

To appeal a denied claim means to spend precious time and effort on the appeal process, even without the guarantee of a successful outcome. Here are a few reasons why you should still try to appeal insurance denials:

• You May Win. While the figures vary, some speculate that you have about a 60% chance of winning a denied medical claim appeal—if the appeal is filed correctly, that is. With the help of a service like aJust, you can rest assured that your appeal is set up for success. Even if your first appeal doesn’t get you the desired outcome, you have the right to a further appeal through your health insurance company or an external review service.
• Extra Time. Appealing a denied claim buys you extra time before you need to pay your medical bill. While you wait for your insurance company’s decision, you can work on establishing a plan B to afford your medical bills.
• Continuation of Treatment. If you receive a denial for a service that you’ll need again (such as the first of many prescribed physical therapy sessions), that one denied medical claim can suddenly disrupt your treatment. In that case, an appeal is crucial, as the denied medical claim has implications for the future, not only the present.

What the Appeal Process Looks Like

While the health insurance appeal process varies depending on your insurance company and individual plan, here is what you can expect:

• First, you’ll learn of the medical claim denial, either through an Explanation of Benefits letter from your health insurance company or a bill from the medical facility.
• Next, you’ll have to reach out to your insurance company by phone, mail, or online through a portal or app. From there, you’ll file an official appeal with the help of a customer service agent.
• It’s time to hurry up and wait! Appeal decisions can take months to come through. Either your health insurance will reverse their decision and pay for the service (minus your copay or deductible if applicable), or they’ll stick by their original decision.
• Some health insurance plans allow you to try for a second appeal. The process may differ from the first appeal or require a letter from your doctor. You may be required to submit an appeal letter as well—more about that later!
• If you still aren’t successful, you can then file an external appeal. This will be processed by an independent organization that handles such matters, or by your local government.

Don’t fight a denied medical claim alone—reach out to aJust today!

Tips for Writing an Appeal Letter

Many health insurance plans require that you submit an appeal letter with your denied claim appeal. Keep these tips in mind when writing your appeal letter:

• Follow Directions. In order to avoid losing your shot at an appeal due to an oversight, follow all directions your insurance company provides. This may mean including specific information or formatting your letter a certain way.
• Include Important Information. In your appeal letter, you’ll want to include information like your name, birthdate, and member ID number, along with the date of the denial and the contact information of the doctor who provided the service.
• Be Convincing. This is your chance to convince the health insurance company why they should appeal the denied medical claim. Remember that the goal of your insurance company is to save their business money. With that in mind, explain how receiving this denied treatment will help you avoid racking up further health costs in the future. Articulate why you believed this service would be covered and how you think it fits into your health insurance plan.
• Provide Supporting Documents. Once you’ve written a winning appeal letter, include all the supporting documents you have. This could include a letter from a medical professional, test results, and any paperwork you received about your medical claim denial.
• Get Help from a Professional. Does all of this sound like a job for an expert, not you the patient? That’s because it should be! Even medical professionals feel overwhelmed with the insurance appeal process, which is counterintuitive and time-consuming. So get help from a professional, like aJust, and take uncertainty out of the equation.

How to Get Started

Ready to get help appealing an insurance denial? Once you’ve gathered your documents, fill out this two-minute form to learn how aJust can help. Instead of spending hours on hold with the insurance company, you can dedicate your time to the responsibilities and joys of daily life while aJust takes care of your denied medical claim.