If Your Health Insurance Claim Is Denied
It’s not unusual for insurers to deny some claims or say they won’t cover a test, procedure, or service that doctors order. You can appeal many types of health insurance decisions – sometimes even things that are written into your health plan’s contract. You can appeal Medicare claim denials, too.
Find out how long you have to file an internal appeal. If the insurer denies a claim, it must explain to you your right to appeal the decision. If you ask for it, they must give you all the information about the decision.
Steps to take before you make a formal appeal
If your claim is denied, you might ask for more information from a customer service representative or case manager at your insurance company before you make a formal appeal. It’s a good idea to:
- Contact your health plan administrator to find out more about the refusal.
- Ask for a full explanation of why the claim was denied.
- Review your health insurance plan's benefits.
- Ask the doctor to write a letter explaining or justifying what has been done or has been requested.
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 does not 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 the decision to deny payment.
- Request a written response. (Keep the originals of all the letters you get; your cancer 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. 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 the National Association of Insurance Commissioners (contact information is in the More information section).
- Do not back down when trying to resolve the matter.
- Consider legal action.
Making a formal appeal
- 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. The cancer care team may also be able to help you with this.
- 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. (You find out online at www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/. 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.html or you can call them at 1-866-470-6242.
- Be persistent. Don’t back down.
- Find out about getting an external review. If the internal appeal doesn’t work, that will be the next step.
The external appeals process
If your internal appeal is denied, you may be entitled to an independent external review by people outside your health plan. If you or your child has employer-sponsored coverage, you might have to file a second internal review before you can file for an external one.
Check with your insurance company about the process. For an urgent health situation, 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 your plan (or your child’s plan) does. If so, you can call the US Department of Health and Human Services contractor, MAXIMUS, at 1-877-549-8152 for information or an external review request form. You can also visit www.cms.gov/CCIIO/Programs-and-Initiatives/Consumer-Support-and-Information/csg-ext-appeals-facts.html to learn more about external appeals.
If your health insurance company is using the HHS-administered external review process, there’s no charge to you for the appeal. If your company has contracted with an independent reviewer, or is using a state external review process, you may be charged. If so, the charge can’t be more than $25 per external review.
Getting help with the appeals process
If you need help filing an internal appeal or external review, your state’s Consumer Assistance Program (CAP) or Department of Insurance may be able to help you. The “More information from your American Cancer Society” section has contact information.
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 bills to get paid faster.
If you can’t resolve your problem directly with the health plan
It helps to know who regulates a health plan if you have a problem that you can’t resolve directly with them. You can talk to the government group that regulates the health plan to find out if they can offer more information or extra help. Contact information for most of them are listed in “To learn more.”
Private group plans (or fully insured plans) purchased from insurance carriers by employers as a benefit for employees are usually overseen by the insurance commissioner or department of insurance in each state. You can find your state’s insurance department in the blue pages of your local phone book, or contact the National Association of Insurance.
Self-funded plans (or self-insured plans) are health plans that employers or unions create just for their employees and their families. They are overseen by the US Department of Labor’s Employee Benefits Security Administration. Because employers often contract with insurance companies to administer these plans, it’s difficult to tell if a work-based plan is self-insured. You will have to ask your employer if your health plan is self-insured.
Individual plans sold through the health insurance marketplaces are regulated by a marketplace board in every state. This state board oversees the function of the marketplace and the plans sold within it.
Managed care plans are regulated by several state and federal agencies. Your state insurance commissioner or department of insurance can provide specific information about an individual plan.
Medigap policies (Medicare Supplement Insurance policies) are regulated by federal agencies, as well as some state laws. Contact the Centers for Medicare and Medicaid Services (CMS) and/or your state department of insurance for information.
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 Veteran’s Health Care system is regulated by the US Department of Veteran’s Affairs.
Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is run by the VA Chief Business Office Purchased Care.
Along with the American Cancer Society, other sources of information and support are listed below.
National Association of Insurance Commissioners
Toll-free Number: 1-866-470-6242
Website: http://naic.org/state_web_map.htmOffers 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 (for those with Medicare)
Toll-free number: 1-800-333-4114
This service can help you understand your rights and benefits, work through the Medicare system, and get quality care. They can also help you apply for programs that help reduce your costs for prescription drugs and medical care, and guide you through the appeals process if your Medicare prescription drug plan denies coverage for drugs you need
Patient Advocate Foundation (PAF)
Toll-free number: 1- 800-532-5274
Works with the patient and insurer, employer and/or creditors to resolve insurance, job retention and/or debt problems related to their diagnosis, with help from case managers, doctors, and attorneys. For cancer patients in treatment or less than 2 years out of treatment.
Last Medical Review: November 18, 2015 Last Revised: February 29, 2016