- Thinking about the costs of cancer treatment
- Private health plans
- Types of private health plans
- Other things to know about health insurance
- How to manage your health insurance
- Getting answers to insurance-related questions
- Keeping records of insurance and medical care costs
- When you have problems paying a medical bill
- Handling a claim denial
- Keeping employer-sponsored health insurance coverage when you leave your job
- COBRA (Consolidated Omnibus Budget and Reconciliation Act of 1986)
- The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
- The Family and Medical Leave Act of 1993
- The Americans With Disabilities Act of 1990
- The Affordable Care Act
- Government-funded health plans
- Who regulates insurance plans?
- Health insurance options for the uninsured
- State coverage and health insurance options for the hard-to-insure
- Financial issues: Getting help with living expenses
- Getting money from life insurance policies
- Other sources of financial help
- Disability benefits
- To learn more
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 Affordable Care Act law now has requirements and timelines when the 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 rules, 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 covered under 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.
- 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 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 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 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 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.
Last Medical Review: 06/24/2013
Last Revised: 08/05/2013