If Your Health Insurance Claim Is Denied

Sometimes insurers deny claims or say they won’t pay for a test, procedure, or service that your healthcare provider orders. You have the right to appeal most insurance denials.

Health insurance denials

Insurance claim denials can happen at any point during your cancer journey. This can be frustrating, but your healthcare team will work with you to appeal them.

Your insurer may deny certain treatments, tests, procedures, or medicines ordered by your healthcare provider. Sometimes, these denials may require your cancer care team to change your treatment plan. Some studies also show that these denials can lead to delays in care.

Appealing an insurance denial

An appeal is a process to provide more information and ask the insurer to reconsider covering the care needed. If you receive an insurance denial related to your cancer care, you or your cancer care team can try to appeal.

Stay organized through the appeal process. Request denials in writing and keep the originals of all the letters you get. Keep a record of dates, names, letters, and calls related to your claims and denials.

Types of appeals

There are two types of insurance appeals.

• Internal reviews are submitted to your insurance company. The appeal asks them to change the decision about a pre-approval request or paying a claim.
• External reviews are submitted to independent organizations outside your insurance company. This is an option if your insurer still denies the claim after an internal review.

Before filing an appeal

If your insurer denies a claim, they must tell you that you have a right to an appeal and how to file one. Make sure to find out the deadline so the appeal can be filed before it.

Resubmit the insurance claim

Before you file an appeal, your or your healthcare team can try resubmitting your claim with the following:

• A copy of the denial letter
• Your doctor's explanation of why the care was needed
• Any other written information supporting the need for the denied test or treatment

Sometimes, the claim just needs to be “coded” differently to be approved for coverage. The insurer will let you know if this is the case, and your healthcare team can make the billing code update.

Find out the reason for the denial

If you ask, the insurer must explain the reason for the denial. You can ask for more information from a customer service representative or case manager at your insurance company. Building a relationship with a case manager early can be helpful in case you need support in the future.

Filing an internal appeal

If resubmitting your claim does not resolve the denial, an internal appeal may need to be submitted. There are two ways you can submit an internal appeal. You can do this yourself, with your care team, or get outside help.

Submit the appeal yourself or with your care team

• Formally appeal the denial in writing, explaining why you think the claim should be paid. Your cancer care team may be able to help you write the appeal.
• Follow up until the denial is resolved.

Get outside help

• Get help from the consumer services division of your state insurance department or commission.
• Find out if you live in one of the US states that has a Consumer Assistance Program (CAP) that can help you file an appeal.

Filing an external review

• If your internal appeal is denied, you can ask for an external review. External reviews are most often used when care was denied based on lack of medical necessity, clinical judgement, or that the treatment is investigational or experimental.  

Ask your insurance company how to request an external review.

For an urgent health situation, you may be able to ask for an internal and external review at the same time.

Learn more about external reviews and the laws that apply on the Centers for Medicare & Medicaid Services website.

If your appeal is still denied

If your claim is still denied after internal and external appeals, ask the healthcare provider if the bill can be reduced. Many providers are willing to reduce bills so they can get paid faster.

If this doesn’t resolve the denial, you can take your appeal to the government body that regulates your health insurance plan.

Talk to health plan regulators

Different health plans are regulated by different government agencies. The agency that regulates your health plan may be able to offer more information or help.

Commercial and employer plans

• Private group plans (or fully insured plans) are purchased by employers as a benefit for employees. They are usually regulated by the state’s insurance commissioner or department of insurance. You can find your state’s insurance department by contacting the National Association of Insurance Commissioners.
• Self-funded plans (or self-insured plans) are health plans that employers or unions create for their employees and families. They are run by the US Department of Labor’s Employee Benefits Security Administration. Ask if you’re not sure whether your employer is self-funded.
• Individual plans sold through health insurance marketplaces are regulated by a marketplace board in each state.
• Managed care plans are regulated by several state and federal agencies. Your state insurance commissioner or department of insurance can provide specific information about a plan.
• Medigap policies (Medicare Supplement Insurance policies) are overseen by federal agencies, as well as some state laws. Contact the Centers for Medicare and Medicaid Services (CMS) or your state department of insurance for information.

Government programs

• Medicaid and CHIP are joint programs that are controlled by your state health department and the federal Centers for Medicare and Medicaid Services.
• Medicare is run by the federal Centers for Medicare and Medicaid Services.
• TRICARE is overseen by the US Department of Defense.
• The Veterans Health Administration is regulated by the US Department of Veterans Affairs.
• Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is run by the VA Chief Business Office Purchased Care.

Getting more information

Your healthcare or cancer care team should have a staff member that can help you with questions regarding insurance denials and appeals.

But these organizations can help you at any stage of the appeals process, too.

National Association of Insurance Commissioners
Toll-free Number: 816-783-8500
Email: help@naic.org
Website: content.naic.org/state-insurance-departments

This offers contact information for your state insurance commission. You can contact your state insurance commission for insurance information specific to your state, or report problems with your insurance company.

Medicare Rights Center
Toll-free number: 1-800-333-4114
Website: www.medicarerights.org

If you have Medicare, this service can help you understand your rights and benefits. It can help you navigate the Medicare system and get quality care. They can also help you apply for programs that help reduce your costs for prescribed medicines and medical care. And they can guide you through the appeals process if your Medicare prescription drug plan denies coverage for medicines you need.

Patient Advocate Foundation (PAF)
Toll-free number: 1-800-532-5274
Website: www.patientadvocate.org

This program works with people and their insurers, employers, and creditors to resolve insurance, job retention, and debt problems related to their diagnosis. It includes help from case managers, doctors, and attorneys. This is typically for people with cancer in treatment or less than 6 months out of treatment.

Questions about health insurance?

Contact the ACS cancer helpline to get answers and information.