Even people with health insurance may experience financial difficulties seeking timely care. Learn your rights and how to file a claim if your health insurance claim has been refused. A personal injury lawyer can assist you and your healthcare team in better understanding how to properly appeal a denial of a health insurance claim.
Appealing a health insurance claim denial
After you receive treatment, services, drugs, or medical products, your healthcare practitioner will normally submit a claim to your health insurance carrier. The insurance company examines the claim and determines whether or not your health plan covers the treatment and how much the provider should be compensated. This selection has an impact on how much you pay.
A health insurance company may refuse or pay far less than you thought. If you feel your health plan should cover the cost of the care, you can file an appeal.
What is a health insurance claim?
A health insurance claim is a reimbursement request made to your health insurance company by you or your health care provider after receiving services, treatment, prescriptions, or medical items you feel are covered by your insurance plan. An approved claim pays the bill in full or part and reimburses the provider or patient.
Reasons for denial of health insurance claim
A claim may be denied by a health insurance company for a number of reasons, including:
- The healthcare provider is not in your plan’s network.
- The plan does not cover the service, medication, treatment, or goods.
- The therapy or service is regarded as medically unnecessary or inadvisable.
- Your coverage has lapsed, or you are not enrolled with the insurer.
- The treatment is considered investigational or experimental.
- Your insurer requires preauthorization or a referral from your primary care physician.
- The claim was not filed on time.
- The claim was not handled successfully due to a paperwork or data input issue.
How to appeal a denied health insurance claim?
There are two ways to appeal a health insurance claim denial: internal review appeals and external review appeals.
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Internal review
An internal review appeal, also known as a “grievance procedure,” asks your insurer to reconsider its decision to refuse coverage for your claim. You have the option of filing an internal appeal. By doing so, you request that your insurer conduct a fair and thorough review of its decision.
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External review
You can file an external review appeal if your insurer rejects coverage for a disputed claim. An independent third party does this. The term “external” refers to the fact that your insurer will no longer have the final say on whether or not to pay a claim.
