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Making benefits claims

Do you have any tips on filing a health benefits claim?

Yes. The first step you should take even before filing a claim is to carefully read your health plan’s summary plan description (SPD). This is a document that your health plan administrator must give you (in writing or electronically) after you join the health insurance plan. This plan summary will tell you how the plan works, what benefits it provides, and how the benefits may be obtained or the process for filing your claim. It should also describe your rights and protections under ERISA (the Employee Retirement Income Security Act).

Each SPD should show you the procedure for filing a claim. Some plans may require you to file a claim (or get prior authorization, which is permission for treatment) before you can get medical treatment. Some have special rules for urgent (emergency) care. For other plans, you must turn in a claim for reimbursement (to get paid back the covered portion) after you pay for the care yourself.

Follow the steps outlined in your SPD when filing your claim. If you cannot find the steps, or don’t understand them, call your plan administrator. You may also contact the Department of Labor’s Employee Benefits Security Administration to help you understand your rights; see the “To learn more” section for contact information.

Your plan should state the time within which it must give you the decision on each claim you turn in. Be sure to look for this time limit in your SPD. When you submit a claim to your plan, note the date and keep track of the time as you wait for a decision. Some plans have different time periods depending on the nature of the benefit claim. For example, the claim for urgent care may be different and the claim may be filed before or after medical care is received. If you don’t get a response from your plan within the stated time period, contact your plan administrator. See our document Health Insurance and Financial Assistance for the Cancer Patient for more information.

What if my claim is denied?

Your plan may deny a claim for many reasons. For example, you may not have yet paid the amount of the yearly deductible. The requested treatment may be something the plan says is not covered or medically needed. Or you may not have given enough information for the plan administrator to process the claim. Look for the reason and other information provided in the notice of denial so that you can figure out if you want to appeal the decision.

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 plans), 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 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.
  • Contact your health plan administrator to find out more about the refusal.
  • Ask the doctor to write a letter explaining or justifying what was done or what’s being requested.
  • 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 rules apply and which appeals process to follow.
  • Talk to your state insurance department or commission, which regulates your insurance company, to verify that the insurance company has acted properly and that the denial has not been made in error. (Check the blue pages of your local phone book or visit the National Association of Insurance Commissioners online at www.naic.org/state_web_map.htm.)

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 to be paid.

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) 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 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 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.
  • If your internal appeal is denied, find out about getting an external review. See our document called Health Insurance and Financial Assistance for the Cancer Patient for more information.

You also may wish to get in touch with the Department of Labor’s Employee Benefits Security Administration about your rights under ERISA. See the “To learn more” section for contact information. You can learn more about claim denials in our document called Health Insurance and Financial Assistance for the Cancer Patient.


Last Medical Review: 12/31/2013
Last Revised: 12/31/2013