Help for Appealing Your Insurance Denial
What is an insurance denial?
When you receive medical services or treatment, your doctor or other health care provider (provider) will submit a request for payment to your insurance company. These requests are often submitted before you receive the treatment or service but sometimes they are submitted after. Usually, payment will be sent to the provider and you will receive an Explanation of Benefits (EOB) that includes the treatment, date of service, what is covered, and what the provider may bill you for (for example, if a co-payment, co-insurance, or deductible applies).
However, if there is disagreement about the treatment your doctor provided or recommends, you will receive an EOB or a letter that says insurance coverage is not authorized. This is an insurance denial. Information about how to appeal the denial or ask the insurance company to reconsider the decision will be included with the EOB or denial notice. Under the Affordable Care Act, you can submit an appeal of a denial when your insurance company decides:
- that you are not eligible to enroll in the health plan
- to not pay for a service that is a benefit under your plan
- to reduce or terminate a covered service that you have been receiving under your health insurance
- that care is not medically necessary
- that you are not eligible for a particular benefit
- that the treatment is experimental or investigational to cancel your coverage
What is not an insurance denial?
If you have questions about your insurance, such as, what you pay for your premium, your deductible amount, or whether your doctor is in-network, these are not considered insurance denials. A denial involves a decision by the insurance company regarding whether a particular medical service should be paid for under your plan. If you have a complaint about your health plan that does not involve a specific treatment denial, you may still file a complaint or grievance with your insurance company. You should check your health plan or call the number on your insurance card to learn more about its grievance process.
Please note: accessing Health Law Advocates' website does not create an attorney/client relationship. This information is not legal advice. The contents are intended for general purposes only. Legal advice depends on the specific facts and circumstances of each individual's situation. Those seeking specific legal advice concerning a health insurance denial should call HLA at 617-338-5241 to find out what assistance we can provide.
This website contains the following information to help you appeal a denial:
Frequently Asked Questions
What decisions by my insurance company can I appeal?
You can appeal to your health plan when there has been a decision by the health plan to deny, reduce, or suspend a health insurance benefit, or a decision to terminate or rescind your health insurance coverage. This is commonly called a denial, but is also referred to as an "adverse benefit determination."
If you have a complaint about your health plan that is not related to a particular service denial, you may be able to submit a member grievance. For example, if your insurer says it will not pay for a service because of other health insurance you have, you may be able to submit a grievance. You should check your plan documents or call your insurer for information about your health plan's grievance process.
How do I prepare for sending in an appeal?
You should carefully review your health plan and any correspondence from your insurance company. You may request a copy of the standard or requirements used by your insurance company and other document relating to your denial, also known as a "claim file," and should receive that information for free. Frequently, the decision by your insurance company will depend on how the plan defines what services are covered and whether a treatment is medically necessary given your particular condition. You should also collect copies of your medical records, letters from health care providers, and any other information that supports your appeal.
Your appeal should identify the insurance company's decision you are appealing and clearly explain the reasons why it should be reversed. If the decision involves medical necessity, you should obtain a letter from your doctor stating why the requested service or treatment meets the health plan's definition of "medically necessary" and any other criteria. Though an appeal may be submitted to your health insurer orally (over the phone), we strongly suggest that you submit your appeal request in writing and keep a copy of your submission.
Read more about requesting the claim file and step-by-step instructions for appealing an insurance denial in HLA's Guide to Appeals .
What is the difference between a fully-insured and self-insured plan?
In a fully-insured employer-based health plan, the employer purchases a health plan from a health insurance carrier and the health insurance carrier bears the financial responsibility for paying out the cost of the employee health benefits under the terms of the plan.
In a self-insured (or self-funded) health plan, the employer acts as its own insurer. Though the employer may contract with a health insurance carrier to act as a claim administrator, the employer is financially responsible for paying out the employee health benefits and bearing the total cost. Very large companies are more likely to offer employees a self-insured health plan.
If you are unsure whether your health plan is self- or fully-insured, ask your insurance company, employer, or broker.
I purchase my health insurance plan for myself or my small business. Is it fully-insured or self-insured?
If you purchase a Commonwealth Choice or Business Express health plan through the Health Connector or purchase an individual health insurance plan through a broker or directly from a health insurance company in Massachusetts, you likely have a fully-insured health insurance plan. If you are unsure of what type of plan you have, ask your insurance company or broker.
How do I appeal a health insurer's decision?
If your health plan sends you a denial or an adverse benefit determination with respect to your medical treatment, it must notify you of your right to appeal and describe the appeal process. There are two types of appeals; an internal appeal that is reviewed by the insurance company itself, and an external appeal that is reviewed by an independent organization. In some cases, the internal appeal process must be exhausted before filing an external appeal. When there is an urgent medical need, you may be able to file both an internal appeal and an external appeal at the same time.
An internal appeal to the health plan must be submitted within 180 days from the date you receive notice of a denial or other adverse benefit determination. Appeals can be submitted either over the phone (orally) or in writing. HLA strongly encourages you to submit any appeals in writing and to keep a copy of any appeal submissions. You should refer to your plan documents for information regarding where to send your appeal and other information about your plan's specific appeal policy. And for more information on external appeals, see below.
You can also ask whether your doctor or provider will submit an appeal on your behalf.
Read more about insurance plans, external appeals, and suggestions for providers in HLA's Guide to Appeals .
I submitted an internal appeal to my health insurer -but lost. What can I do?
If your internal appeal was denied, you may be eligible to have a review of this decision by an organization outside of the insurance company. Almost all health insurers are required to offer an external review process to members who have exhausted the internal appeal process, but still disagree with the health plan's decision. An external review is an appeal that is reviewed by an independent review organization, or IRO, that is not associated with the health plan. The IRO's decision is final.
While some insurance plans require only one internal appeal, others require you to complete a second internal appeal before you have a right to an external review. If your appeal pertains to urgent medical care, you may be able to obtain internal and external reviews at the same time.
Your denial letter should indicate whether you have received the insurance company's final decision on your appeal and whether you are eligible for an external review. An external review is typically only available for health plan decisions that are based on whether a requested service or treatment is medically necessary. You should keep in mind that you may (and it is a good idea to) include additional information in submitting another internal or external appeal if you have been unsuccessful so far in the appeals process. You may want to contact your provider(s) and obtain additional medical records and/or letters of support for your next appeal.
If you are covered under a fully-insured health plan in Massachusetts, you must request an external review through the Office of Patient Protection (OPP). You can find more information about the OPP external review process here.
If you have a self-insured or self-funded health plan and it was not in existence on or before March 23, 2010, your health insurer must provide an external review process that is compliant with federal rules. You should refer to your denial letter and specific health plan documents for information about an external review. If you have trouble finding information about your external review rights, you can call the United States Department of Labor's Employee Benefits Security Administration at 866-444-EBSA.
When will I get an answer on my appeal?
If you are appealing a denial of coverage for services you have not yet received the health plan must issue a decision within 30 days. For a denial of treatment you have already received, the health insurer must issue an internal appeal decision within 60 days. If your health or life is in jeopardy, you may be entitled to an expedited appeal-see below for more information on expedited appeals.
If you completed the internal appeal process and the treatment was still denied, you can send in an appeal for external review by an independent organization. An external review decision must be issued within 60 days. However, for an urgent medical need, you may be eligible for expedited external review-see below for more details.
I have an urgent medica l need and need a decision quickly. What can I do?
Most health insurers are required to offer an expedited appeal procedure when your life or health is in jeopardy. Your doctor may need to authorize your request for an urgent, expedited appeal. If your internal appeal is deemed urgent, the health plan must issue its decision within 72 hours.
If your internal expedited appeal is denied, you may be eligible to request an expedited external review. The decision for an expedited external review must be issued within 4 days of receipt by the reviewing organization. You may also be able to pursue an expedited external appeal at the same time that you file an expedited internal appeal. For more information about urgent appeals, you can refer to your health insurance plan documents or contact member services.
Can someone help me with my appeal?
Yes. You may appoint an authorized representative to assist you in the appeal process. You will need to submit a signed authorization form to your health insurer that will authorize communication with your representative on your behalf. This authorization is required when a family member, even a parent or spouse, is helping you. You can often find these forms on your health plan's website or by calling the customer service phone number on your member identification card.
If you live in Massachusetts and need assistance submitting an appeal, you may call Health Law Advocates at (617) 338-5241 or email us. HLA staff can answer your general questions about the appeal process and will talk with you to determine if we can provide assistance with your appeal. If you live in another state, you can find out about the resources that are available to help you with your health insurance appeal questions here.
For a sample authorization letter and step-by-step instructions for writing an appeal, see HLA's Guide to Appeals .
Insurance Plan Basics
While many people have never reviewed their insurance plan documents, it is important to read them now because knowing what your plan covers will help you develop the basis for your appeal. Your plan may be available on your insurer's website. If
not, you should call your insurance company and request a copy of your plan. Be sure to ask for the entire plan (it may be called the Member Handbook, Benefits Handbook, or Evidence of Coverage) and not a summary because you are looking for the most comprehensive information that is available.
Also, be sure to request and review the plan that was in effect at the time your treatment or service was requested. If, for example, your plan year is from January 1 through December 31 and your service was requested and the denial was issued in December 2012 you need the 2012 plan. If, on the other hand, the service was requested and denied in January 2013, make sure you request and review the plan in effect for 2013.
For more information about insurance plans and a glossary of common terms and their meanings, see HLA's Guide to Appeals .
Requesting the Claim File
In order to make a successful appeal, you must first understand the basis for the health insurer's denial and be able to provide support for why you meet the standard that is being applied by your insurer. If you and/or your doctor do not understand the reason for denial, you should request your "claim file" from the insurance company. Your claim file is a copy of the criteria or standards that were used and all of the documents related to your claim.
The denial letter or notice from your insurance company should explain how to request copies of this information at no charge. If there is no information in the denial about how to do that, you can check your plan or call your insurance company and ask about it.
It is important to submit your request for the claim file in writing and keep a copy so that you can keep track of when it was submitted.
For help with requesting a claim file and a sample letter, see HLA's Guide to Appeals.
7 Steps to an Insurance Appeal
Convincing an insurance company to reverse a decision to deny a treatment may not be easy, but if you take a step-by-step approach, you may increase your chances of success. Here are some suggestions for how to do just that:
1. Get organized and keep everything in one place. Have a notebook or file to help keep track of all of the documents. Keep good records and save all correspondence from your insurance company. Ask for a name and/or confirmation number for each call you make to the health insurer and keep complete notes. If you receive conflicting or confusing information, follow up with the health insurer in writing.
2. Do your homework. Review the denial letter so you know what is being denied, and why. If you do not understand the denial, request a copy of the claim file, the insurer's standards and records relating to the denial. This information should be provided free from your insurance company. Determine what these documents say about appealing the decision, including when appeals must be submitted.
3. Review your health plan and the services for which you are eligible for coverage. If you do not have a copy of your plan, request one from the insurance company. Research the terms that are in your denial letter and how they are defined in the plan.
4. Talk to your doctor(s) or someone in your doctor's office about the denial and provide a copy of the denial notice if they have not received it. Ask for any information and copies of medical records that would support your appeal. Decide whether you want to appeal the decision or ask your doctor to do so. If your doctor agrees to file the appeal, make sure s/he understands what is required.
5. If you are going to submit the appeal yourself be sure to include the criteria used, the denial letter, your medical records, and include copies of those documents (not the originals). Ask your doctor to write a letter of support referencing the insurer's criteria. You may want to include a personal statement, but otherwise, stick to the facts. Before sending your appeal, have a friend or family member review it to give you feedback.
6. Send the appeal by certified mail with a return receipt, so that you know when it was received. Be sure to keep a complete copy of everything you send.
7. If your appeal is denied you may be able to try again if you are eligible for another internal appeal or an external review. Review the denial letter carefully to see what other information or medical records might be helpful in your next appeal. Pay attention to the deadline for submitting another appeal.
For more information on writing an appeal and a sample letter, see HLA's Guide to Appeals .
Suggestions for Providers
This information is meant to serve as a guide if your patient's health insurance company has denied the medical service or treatment you recommended. In general, a service must be covered it is a covered benefit under the health plan and the patient's need for the service meets the health plan's medical necessity criteria.
In appealing a denial, it is important to provide the information and documentation that supports how this service addresses the patient's specific medical needs. Before agreeing to submit an appeal on your patient's behalf, please consider the importance of taking this step because it may be the patient's only opportunity to obtain coverage for this service.
Before drafting the appeal, you should:
1. review the insurance company's denial to understand why coverage for this service was denied. If you do not understand it, please call the insurance company to get more information and request the criteria that were used; and
2. review the medical records to ensure there is supporting information and documentation for the treatment you are recommending.
If you prefer that the patient obtain this information, please let him/her know as soon as possible because appeals are time-sensitive. If you are unable to submit the appeal on the patient's behalf, you can still help by writing a letter of support that can be included in your patient's appeal. In fact, a strong letter of support from a provider can mean the difference between whether an appeal is successful or not.
In general, when drafting a letter of support, you should include as much detail as possible concerning the patient's particular medical needs, how the insurance plan's standards or criteria are met, and copies of all medical records that support your statements. If you do not have sufficient information or knowledge to draft such a letter, you should tell the patient so s/he can locate another provider to assist with the appeal.
For more help on submitting an appeal or drafting a letter of support, see HLA's Guide to Appeals .
Glossary of Terms
Adverse benefit determination -a decision by your insurance company to deny or reduce payment for a particular medical service, or terminate your health insurance coverage.
Affordable Care Act- the national health care reform law signed by President Obama in 2010.
Claim file -all of the information and documents involved in an insurer's review of a requested treatment or service which should be provided at no cost to you.
Co-insurance -a percentage of your medical care costs that you are required to pay under your health plan for a particular type of care.
Coordination of Benefits -when an individual is covered by two or more insurance plans, this determines how much of a treatment or service each plan covers.
Co-payment -what you are required to pay each time you obtain a particular type of medical service, such as office visits or prescription drugs.
Deductible -the total amount you must pay for medical treatment before your health plan will start covering the cost of your medical care for you and/or your dependents.
Denial -a decision by an insurance company not to pay for treatment either before it is delivered or after you have already received it.
Eligibility -whether a person has the right to coverage. Eligibility can vary based on the particular health plan, the provider, service area, or the treatment/service sought.
Exclusion -a service or treatment that is not covered by your plan.
Explanation of benefits or EOB -this is the notification the insurance company sends after processing a claim. It should include the treatment, date of service, what is covered, and what the patient should pay (for example, if a co-payment, co-insurance, or deductible applies).
External appeal or external review -an appeal that is not reviewed by your insurance company, but is sent to an independent review organization for a decision.
Fully-insured plan -a health plan in which the insurance carrier bears the financial responsibility for paying out the cost of health benefits under the terms of the plan. A fully-insured plan may be an individual or group plan that is offered through your employer.
Grandfathered plan -a health plan that was in effect on March 23, 2010 and which has not changed substantially since that date. The appeal protections in the Affordable Care Act do not apply to grandfathered plans.
Independent Review Organization or IRO -an entity that conducts reviews of an insurance company's final decision not to cover a service or treatment. The IRO's decision is final.
Internal appeal -an appeal for a denial of medical treatment or cancellation of coverage that is submitted to and reviewed by your insurance company. A plan may require one or two internal appeals.
Medically necessary or medical necessity -a standard used by an insurance company to determine whether treatment or services are appropriate and effective given a patient's health needs. Frequently a health plan will include a list of requirements that must be met in making this determination.
Out-of-Network Provider -a medical provider (such as a doctor or treatment center) that has not contracted with your insurance plan to provide medical services at a negotiated rate. The patient may be responsible for all charges depending on what the specific health plan covers.
Out-of-pocket maximum -the total amount you will pay for medical care that includes your co-insurance and deductible amounts, but usually not co-payments. Once your out-of-pocket maximum is reached, your health plan covers all of your medical expenses.
Preauthorization or prior authorization -a request by your provider to have a particular service or treatment approved by your insurance company.
Provider -a doctor or someone else who is qualified to deliver medical services.
Rider -a condition or additional provision that is added to a policy that changes the benefits provided.
Self-insured plan -a health plan in which the employer pays for the actual cost of the health benefits provided to employees. A self-insured plan is usually purchased by a large employer or union but which can be administered by a third party.
Urgent appeal -an expedited appeal you can make if withholding medical care places your life or health in jeopardy.
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