How to Appeal a Decision by Your Health Insurance Company
Sometimes, insurance companies deny claims or make decisions you disagree with—but don’t worry, you have the right to appeal.
This guide will walk you through the general steps to appeal a health insurance decision.
Reminder: Whenever possible, check with your insurance company before receiving a healthcare service to ensure it is covered. You can find the company’s contact information on the back of your insurance card. A quick call beforehand can save you significant time and effort later. Be sure to ask your healthcare provider for the specific billing codes for the service in question, as these codes will help you confirm your coverage with your insurance company.
Step 1: Understand the Denial
Review the Explanation: Carefully read your denial letter. It should explain why your claim was denied or why the decision was made.
Check Your Policy: Match the reason for denial with the terms in your insurance policy to see if there’s been a misunderstanding.
Remember: Always consult your Summary of Benefits and Coverage (SBC). This document outlines the terms of your policy, including the benefits covered and your cost-sharing amounts.
It’s a handy guide to help you understand what your plan does and doesn’t cover.
Insurance companies typically provide the Summary of Benefits and Coverage (SBC) in multiple accessible locations:
Online Member Portal: Most insurance companies host the SBC on their official website within a secure member portal. Log in to your account to view or download the document.
Welcome Packet: When you first enroll in a health plan, the SBC is often included in the welcome materials sent to you, either as a physical copy or electronically.
Customer Service: You can request a copy by contacting your insurance company directly.
The customer service phone number is usually found on the back of your insurance card.
Employer: If your insurance is through your employer, the SBC may also be available from your HR or benefits department.
Step 2: Request Coverage Criteria
Ask for Specific Criteria: Contact your insurance company and request the specific coverage criteria for the denied service or drug. These criteria outline the circumstances under which the service or drug is covered.
Clarify Requirements: Ensure you understand what documentation or medical necessity criteria the insurance company needs to approve the claim.
Step 3: Gather Your Documents
Obtain Supporting Records: Ask your healthcare provider for medical records, bills, and any correspondence they submitted on your behalf to your insurer.
Include Additional Documentation: Provide any evidence or additional documentation that aligns with the insurance company’s stated criteria for coverage.
Step 4: Contact Your Insurance Company
Request Appeals Information: Ask them to explain the appeals process and request the necessary forms or instructions.
Step 5: Submit Your Appeal
Write an Appeal Letter: Clearly state why you believe the decision is incorrect. Include supporting documents and reference specific terms in your policy and the insurance company’s coverage criteria.
Meet the Deadline: Appeals have strict timelines. Submit your appeal promptly.
Step 6: Follow Up
Track Progress: Keep track of your appeal’s status. Stay persistent and maintain records of every call and letter.
Step 7: External Review (if needed)
Request External Review: If your appeal is denied, you can often request an external review by a neutral third party. This decision is binding for the insurance company.