If your insurance provider denies a claim, you have the right to file an appeal
When you receive medical services, your medical provider will submit a request for payment for those services to your health insurance provider (called a claim). your insurance provider may deny full or partial coverage of the claim. if this happens, you can file an appeal. An appeal is a request to review a health insurance provider’s decision regarding a claim. the process of filing an appeal can seem daunting. but it is both your right and your best interest to appeal a denied claim that you and your health care team believe is important to your health.
In 2019, 40.4 million health insurance claims were denied and only 0.02% of those denied claims were appealed (pollitz, 2021). this equates to just 63,318 appeals out of 40.4 million denied claims. however, people who do file an appeal often see results in their favor: “it’s in someone’s best interest to try to appeal, because we know that 40% to 60% of all appeals are decided in favor of the patient” . points out monica bryant of triage cancer.
This blog offers tools, tips, and guidance to empower patients who need to file a health insurance appeal for a denied claim.
It is both your right and your best interest to appeal a denied claim that you and your health care team believe is important to your health.
Before filing an appeal, it helps to understand the different types of insurance appeals:
- internal appeals
- external calls
- expedited appeals
- Individual Plan: This plan is purchased through a state marketplace or directly from an insurance company.
- funded plan: the employer buys an insurance plan from an insurance company and the insurance company covers the medical expenses.
- Self-funded plan: Your employer pays your health care costs directly. Often in this case, employers will contract with an insurance company to administer the plan.
- Medicare: Call 800-medicare (800-633-4227) for free appeal assistance or contact your state health insurance program provider.
- Medicaid: Contact your state Medicaid agency.
- administrative: incorrect encoding
- experimental or investigational: off-label drug use
- not eligible for the service or benefit under your health plan
- not a covered benefit: cosmetic surgery
An internal appeal is where you go back to your insurance company (individual or funded plan) or your employer (self-funded plan) and ask them to reconsider their decision. appeals can take place after you receive a service or before you receive a service. You have 6 months (180 days) from the day you learn your claim was denied to file an appeal. your insurance company then has a set timeline for responding. You can also file an expedited appeal, for example, if waiting a long period of time could cause more harm.
An external appeal can be filed if your insurance denies your original appeal. in this case, go to an independent entity and ask them to examine the facts. this process is based on the specific laws of your state and the decision at this step is final in all cases. You generally have 4 months from the day you learn your claim was denied to file an external appeal. You can also file an expedited appeal, if you qualify.
An expedited appeal is helpful when the time it takes for a standard appeal could harm your health. With this type of appeal, you can file both internally and externally at the same time, if the case allows.
prepare to file an appeal
Step 1: Determine the type of plan you have.
Knowing what type of insurance plan you have will help inform the steps you will take when filing an appeal. Plan types include:
Need help determining what type of health insurance plan you have? triage cancer provides a questionnaire to help you identify your plan. or contact your state insurance department to find out what type of plan you have.
Step 2: Understand the reason for a denial.
here are some examples that may explain why your claim was denied. there may be other reasons not listed here.
Step 3: Gather evidence to prove that the treatment or service is medically necessary.
Work with your medical team to illustrate the need for the treatment or service. this may include a letter from your provider, your medical records, and medical literature to support the medical efficacy of a specific treatment.
Tip 1: When filing an appeal, use a spreadsheet or form to keep track of all your correspondence. this will help you stay on top of what has been completed and what needs to be done.
Tip 2: Organize all your correspondence, notes, copies, and records in one place so you can quickly refer to information about your appeal.
Get help with the appeal process
If you receive a health insurance claim denial, you can contact your state insurance department to point you in the right direction. They can tell you who you can contact for help filing your appeal. Find the contact information for your state insurance department.
“people who are on staff in insurance departments have a great deal of knowledge, they want to share it with you, and they want to help you.”
— Mary Kwei, Maryland Insurance Administration
State insurance departments are also the entities that typically conduct external reviews, should you need to file an external appeal. They can also help you determine if your appeal is eligible for an expedited process.
For additional guidance, triage cancer offers resources to help demystify the appeals process.
Get help with your health insurance questions
We are here to support you. If you have questions about health insurance or other concerns about the cost of cancer care, we can help. Call our cancer support helpline at 888-793-9355 to speak with an experienced patient navigator.
“We want the patient to know that they are not alone in this process.”
— aimee hoch, financial navigator, cancer support helpline
Editor’s Note: On April 25, our Cancer Policy Institute hosted “Health Insurance Appeals 101,” a webinar on the insurance appeals process. This webinar was part of our Utilization Management Forum, which was created to bring patient advocates together in meaningful conversations, ask difficult and nuanced questions, and identify new ideas and practices that optimize evidence-based care. Speakers Monica Bryant from Triage Cancer, Mary Kwei from the Maryland Insurance Administration, and Aimee Hoch from the Cancer Support Community discussed what patients and caregivers need to know about the insurance appeals process. Monica, Mary, and Aimee highlighted resources that will help you file an insurance appeal.