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Dealing with a claim denial

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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 the full cost. 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 plan does not cover complementary medicine.

As part of the Affordable Care Act, insurance companies can no longer drop or limit coverage if you choose to enroll in a clinical trial.

Steps to take if your claim is denied

  • 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 policy reasons.
    • If information is missing or incorrect, work with your healthcare 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 a 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 is to handle appeals and provide documentation of your treatment and needs. Have your doctor write a letter to the insurance company and keep a copy for your records.
  • File an external appeal claiming that your care is “medically necessary,” if you have the option. 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.
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Reviewed and updated: August 31, 2015

Reviewed by: Joanna L. Fawzy Morales Esq

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Living Beyond Breast Cancer is a national nonprofit organization that seeks to create a world that understands there is more than one way to have breast cancer. To fulfill its mission of providing trusted information and a community of support to those impacted by the disease, Living Beyond Breast Cancer offers on-demand emotional, practical, and evidence-based content. For over 30 years, the organization has remained committed to creating a culture of acceptance — where sharing the diversity of the lived experience of breast cancer fosters self-advocacy and hope. For more information, learn more about our programs and services.

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