On average, health insurance providers on the healthcare.gov ACA Marketplace denied 1 in 5 in-network health insurance claims (18%), according to a 2019 report by the Kaiser Family Foundation, a nonprofit organization focused on national health issues.
Denial rates for certain issuers varied greatly, ranging from 1% to as much as 40% of in-network claims denied, according to the same report.
If your health insurance provider denies your claim, it might be tempting to just give up and pay the medical bill rather than deal with the frustration, phone calls, and red tape of an appeal. However, if your insurance provider is required to cover the claim under your coverage, appealing the denial could save you money and reduce medical debt.
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1. Know the reason for denial
If your health care provider denies your claim, it must notify you in writing why it denied your claim. The insurer must also provide information about steps you can take to dispute the decision.
2. Review your coverage
If you question the denial of your claim, it’s time to dig up your health insurance policy handbook or access the policy and Summary of Benefits and Coverage (SBC) on your health insurer’s website. Review your policy to find out whether coverage includes the treatment, procedure, type of office visit or other service in question.
Don’t waste your time filing an appeal if the insurer’s decision is clearly based on a lack of coverage. However, if you ascertain that coverage falls under your policy, an appeal is in order.
3. Look up your insurer’s appeals policy
Health insurance providers have rules you must follow to appeal a claim. For example, you must begin with an “internal appeal” where you request that your insurance provider conduct a “full and fair” review of its decision, according to the U.S. Department of Health & Human Services.
If your insurance provider still denies your claim after the internal appeal, you’re allowed by law to file a request for an external review, in which an independent third party will either uphold the insurance company’s decision or decide in your favor. Whatever the outcome, your insurance company must legally accept the reviewer’s decision.
4. Gather relevant documents
Before you contact your health insurance provider, make sure you have all documents you’ll need on hand such as your policy, the Summary of Benefits and Coverage (SBC), the medical bill and insurer’s Explanation of Benefits (EOB) and the denial letter from your insurance company.
The National Association of Insurance Commissioners recommends writing down any questions you have about the claims denial to prepare for calling or corresponding with your insurance company.
5. Make a phone call
Before appealing the denial, try calling the healthcare provider’s billing office to double check that the correct billing codes were entered and that the claim was sent to the proper insurance company. If there is an error, the billing office can resubmit your claim to the insurer.
If information on the medical bill is correct, contact your health insurance provider. The representative you speak with may be able to spot any problems right away, explain why your claim was denied or resolve an issue that resulted in claims denial.
6. Plan your strategy
If you believe your claim was wrongly denied, you can appeal the denial yourself online or by mail with the insurance provider, which should provide rules for appeals and necessary documents on its website.
If your bill is large or you have more than one denial to contest, consider hiring a medical billing advocate, a professional experienced at navigating the appeals process. That way, you can avoid the hassle, annoying phone calls and rage-inducing correspondence while someone else gets the appeals job done.