FAQ

How to file an appeal for health insurance claim

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.

Reading: How to file an appeal for health insurance claim

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
  • 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.

    See also: How to Choose a Health Insurance Plan | Anthem

    Knowing what type of insurance plan you have will help inform the steps you will take when filing an appeal. Plan types include:

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