Health Insurance and Financial Assistance for the Cancer Patient

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Handling a claim denial

It’s not unusual for some claims to be denied or for insurers to say they will not cover a test, procedure, or service that your doctor orders. The new health care law gives consumers more information and the right to appeal a claim denial. For example, an insurer must notify you in writing of a claim denial within 30 days after a claim is filed for medical services you’ve already gotten, and within 72 hours for urgent care cases.

Under the new rules, health plans that are not “grandfathered” (those that began on or after September 23, 2010) must have an internal appeals process that:

  • 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 the insurer denies a claim, it must explain your right to appeal the decision. If you ask for it, the insurer must give you all the information about the decision. Plans that were started before September 23, 2010, are still covered by the old rules (“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 customer service representative for a full explanation of why the claim was denied.
  • Review your health insurance plan’s benefits. This may require looking at the more detailed Summary of Benefits notice.
  • 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 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 (to learn if the new law’s requirements apply or if the plan is “grandfathered”). This will help you figure out which rules apply and which appeals process to follow.
  • Talk to your state insurance department or the agency that regulates your insurance company to verify that the insurance company has acted properly and that the denial has not been made in error. (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 has been denied. Sometimes the test or service will only need to be “coded” differently. If questioning or challenging the denial in these ways 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 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 request an internal appeal (or internal review) 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 doctor. Your cancer care team may be able to help with this.
  • You have 6 months (180 days) from receiving your claim denial to file an internal appeal.
  • Find out if you live in one of the US states that 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.
  • Be persistent. Do not back down when trying to resolve the matter.
  • Find out about getting an external review (see “The external appeals process” below).

The external appeals process

If your internal appeal is denied, you may be entitled to an independent external review, 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 matters, 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 yours does, and if so you can call the US Department of Health and Human Services (www.healthcare.gov) at 1-877-549-8152 for an external review request form. Or, you can visit http://www.cms.gov/CCIIO/Programs-and-Initiatives/Consumer-Support-and-Information/csg-ext-appeals-facts.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 called “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.

If all the internal and external appeals are exhausted, and the claim is still denied, ask the health care provider if the cost of the bill can be reduced. Many providers are willing to reduce the bill to get paid faster.


Last Medical Review: 12/31/2013
Last Revised: 09/08/2014