Handling a Claim Denial

Just because an insurer denies your claim initially doesn’t mean it won’t pay. Here’s how to proceed if your insurer denies a claim.

If you’re facing a health problem, the last thing you want to do is deal with a claims denial. Taking these steps will help smooth the process:

1. Check the reason for denial. Sometimes, an insurer will deny a claim or reject a request for preauthorization simply because the claim form is missing information. Submitting the required information to your insurer can resolve the problem.
2. If the insurer denies a claim for medical reasons, NASE (the National Association for the Self-Employed) recommends making sure the claims denial letter from your insurer includes the following information:
   • the medical reasons for the denial,
   • the name of the specific treatment being denied,
   • the name, state of licensing, medical license number and title of the person making the denial decision,
   • instructions for filing an internal appeal, including whether your appeal has to be in writing, time limits, and the name and phone number of a contact person,
   • instructions for filing an external request for review if the denial is upheld in the internal review. (Source: National Association for the Self-Employed, www.nase.org)
3. Check your plan’s documents (Evidence of Coverage or Summary Plan Description) against the letter of denial or Explanation of Benefits from the insurer. If you’re not sure whether the service is covered or you still feel the service was denied incorrectly, contact your insurer’s customer service department.
4. Keep a copy of the insurer’s letter of denial, along with related correspondence and a log of any calls you make and the resulting conversations.
5. Follow up on any conversations with the insurer’s customer service department. If you still feel the claim is justified and do not get the desired result, you can prepare a formal, written appeal. Your Summary Plan Description or Evidence of Coverage describes the appeal process and any deadlines.
   Your written appeal should include: your contact information, insurance plan number and your member number, a description of the service or procedure, your medical provider’s name and a copy of the bill or request for preapproval, any documentation relating to referrals, and any health information or history that supports your need for the service (your provider can help you supply this information). If you have an urgent need for the service, be sure to note this in your appeal.
6. If the insurer denies your written appeal, you may be able to appeal the decision to a state external review organization. Most states provide for an external or independent review of denied claims. Contact the state’s insurance regulator for more information.
7. Use your broker as a resource. Buying health insurance from a local salesperson, rather than online, gives you access to a real person who can provide service after the sale. If you do not understand the coverage under your policy, please contact us. Likewise, if you have had a claim denied, please contact us—we can help you determine if it should have been paid under the terms of your policy. If questions remain, we can refer you to the appropriate departments.