Dealing with a Claim Denial
Updated October 3, 2013
There may come a time when your insurance company denies a claim, which means they have decided not to pay for a treatment, procedure, or medicine your doctor recommended. A claim denial does not mean that you cannot move forward with that treatment, but it does mean you may have to cover its full cost yourself. There are a few reasons that a claim may be denied.
- If you saw an out-of-network provider, the doctor’s office doesn’t usually submit the claim; you do. Call and check with any out-of-network offices to see if you need to submit the claim.
- A code is missing or is incorrect. Check your explanation of benefits and resubmit the claim if you find errors. The explanation of benefits (EOB) is a document from your insurance company that explains what your plan does and does not cover each time you receive medical care.
- Your insurance company does not cover experimental/investigational expenses.
- Your insurance company does not cover complementary medicine or clinical trials. Learn about the Affordable Care Act and how this will change in 2014.
Steps to Take
- Contact your insurance case manager and ask why your claim was denied. They will be able to tell you if information is missing or if the treatment was denied for medical reasons.
- If information is missing or incorrect, work with your health care providers and resubmit the correct or full information.
- Research, or ask your case manager about, your insurance company’s appeal process, the steps you take to challenge their claim denial.
- Talk with your doctors to find out if the denial is worth appealing. Sometimes the doctor’s office will have a staff member whose job it is to handle appeals and provide documentation of your treatment and needs. Have you doctor write a letter and keep a copy for your records.
- You may be able to file an external appeal claiming that your care is “medically necessary.” To do so, contact your state’s insurance agency.
- Use a professional, such as a medical billing advocate, to help you negotiate with your insurance provider to appeal denials.
- Contact your state’s insurance commissioner or get advice from a lawyer who handles insurance coverage denials.
Learn more about lead reviewer Joanna L. Fawzy Morales, Esq, and the other providers who helped us write this page in our Guide to Understanding Financial Concerns, 1st ed., 2010.