- Children Diagnosed With Cancer: Financial and Insurance Issues
- Insurance is complicated
- Private health plan coverage for children
- How to manage your child’s health insurance
- Getting answers to insurance-related questions
- Keeping records of your child’s insurance and medical costs
- Handling a health insurance claim denial
- Keeping employer-sponsored health insurance coverage when you leave your job
- What if my child’s medical care is covered by more than one insurance company?
- Government-funded health plans
- Who regulates insurance plans?
- Options for uninsured children
- State coverage and health insurance options for the hard to insure
- What sources are available to help with treatment costs if my child doesn’t have insurance and there’s no public assistance available?
- Financial issues for families: Getting help with living expenses
- To learn more
Handling a health insurance claim denial
It’s not unusual for insurers to deny some claims or say they won’t cover a test, procedure, or service that doctors order. Still, there are things you can do when your insurance won’t pay for a prescribed service. The ACA law now has requirements and timelines for when an insurer denies a claim and you want to appeal their decision. For example, they must notify you in writing within 30 days after a claim for medical services you’ve already gotten, and within 72 hours for urgent care cases.
Under the new law, health plans that began on or after September 23, 2010 must have an internal appeals process that does all these things:
- Allows consumers to appeal when a health plan denies a claim for a covered service or rescinds (takes back) coverage;
- Gives consumers details about the reasons for the denial of claims or coverage;
- Requires plans to notify consumers about their right to appeal and how to begin the appeals process;
- Offers consumers a way to speed up the appeal in urgent cases
If they deny a claim, your insurer must explain your right to appeal their decision. If you ask for it, they must give you all the information about the decision. Plans that were started before September 23, 2010 are still under the old rules of coverage (“grandfathered”), although the way you appeal the denial will be the same as for newer plans.
Before you appeal, you may want to take these steps:
- Ask your insurance company’s customer service representative for a full explanation of why the claim was denied.
- Review your health insurance plan’s benefits.
- If your child’s plan is through an employer, contact the health plan administrator at work to find out more about the refusal.
- Ask the child’s doctor to write a letter explaining or justifying what has been done or has been requested. Keep a copy of this letter in case an appeal is needed later.
- Ask your insurer if your employer’s health plan is self-insured, and on what date the plan started. (This is to learn if the ACA requirements apply or if the plan is “grandfathered.”) This will help you figure out which appeals process to follow.
- Talk to your state insurance department or the agency that regulates your insurance company to learn more (see the section “Who regulates insurance plans?”).
You can then re-submit the claim with a copy of the denial letter and your doctor’s explanation, along with any other written information that supports using the test or treatment that’s been denied. Sometimes the test or service will only need to be “coded” differently. If questioning or challenging the denial with these methods doesn’t work, you may need to:
- Put off payment until the matter is resolved. Keep the originals of all the letters you get; your child’s cancer care team may be able to help you make copies if you need them.
- Keep a record of dates, names, and conversations you have about the denial.
- Re-submit the claim a third time and request a review.
- Ask to speak with a supervisor who may have authority to reverse a decision. Formally request an internal appeal, which is done by the insurance company. Complete any forms the insurer requires, or write them a letter explaining that you’re appealing the insurer’s denial. Include your name, claim number, and health insurance ID number, along with any extra information such as a letter from your child’s doctor. Your child’s cancer care team members may be able to help with this.
- You have 6 months (180 days) from receiving a claim denial to file an internal appeal.
- Find out if you live in one of the US states that also have a special Consumer Assistance Program (CAP) that can help you file an appeal.
- If you don’t live in a CAP state, get help from the consumer services division of your state insurance department or commission. Check the blue pages of your phone book or contact the National Association of Insurance Commissioners online at http://naic.org/state_web_map.htm, or you can call them at 1-866-470-6242.
- Do not back down when trying to resolve the matter.
- Find out about getting an external review (see “The external appeals process” below).
- Consider legal action.
The external appeals process
If your internal appeal is denied, you may be entitled to an independent external review, which is done by people outside of your health plan. Note that if you have employer-sponsored coverage, you may have to file a second internal review before you can file for an external one. Check with your insurance company about the process. For urgent health situations, the timelines are shorter, and you may be able to ask for an external review at the same time you ask for an internal one.
Outside or commercial health plans: Most commercial health plans (those offered by insurance companies) take part in the federal external review process. Find out if your child’s plan does, and if so, call the US Department of Health and Human Services at 1-877-549-8152 for an external review request form, or go to www.healthcare.gov/news/factsheets/2012/06/appeals06152012a.html to learn more about internal and external appeals. There you can also get a tracking form to help you keep up with each step of the appeals process.
Self-insured health plans: If your plan is self-insured (see section “Who regulates insurance plans?”), you can ask your insurer how to start an independent external review. Or you can contact the Employee Benefits Security Administration at the US Department of Labor. You can find contact information in the “To learn more” section.
Last Medical Review: 10/07/2013
Last Revised: 10/07/2013