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.

If this happens, it’s important to have a working relationship with a customer service representative at the insurance company or a case manager with whom you can talk about the situation. 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 plan is through your or your spouse’s employer, contact your 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.
• 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.
• 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.
• Request a written response. (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.
• Formally appeal the denial in writing, explaining why you think the claim should be paid. This is the internal appeal, which is sent to and looked at by the insurance company. Your cancer care team members (doctor, nurse, social worker) may be able to help with this.
• 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 appeals process” below).
• Consider legal action.

The health insurance 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. Call the US Department of Health and Human Services at 1-877-549-8152 for an external review request form, or visit 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.

Learning more about appeals for denied insurance claims

The appeals process is also outlined by the Kaiser Family Foundation in “A Consumer’s Guide to Handling Disputes with Your Employer or Private Health Plan” which can be found on their website at www.kff.org/consumerguide.

The Patient Advocate Foundation also has “Your Guide to the Appeals Process” which can be found on their website at www.patientadvocate.org/resources.php?p=13.