How to appeal an insurance company claim denial
The process for appealing health insurance claim denials can have two stages: internal and external appeals. These processes are standardized by the Departments of Health and Human Services, Labor, and the Treasury. Here are the differences between the two.
Submit an internal appeal
An internal appeal is a request you can make to your insurer when it denies a claim. This is typically the first step to disagreeing with your insurer’s claim decision. You have up to 180 days from the date on your denial notice to file an appeal.
During the internal appeals process, fill out all the forms your insurer requires. Submit important or helpful information, like a letter from your healthcare provider. If you need help, contact the Consumer Assistance Program where you live.
Once your insurance company receives your paperwork, it will conduct an investigation and review all evidence presented before making a final decision. Keep in mind, the steps in a health insurance appeal can vary from insurer to insurer, but the basic process for appealing is the same.
How long will the internal appeal take?
If you haven’t yet received the service that you’re appealing, the insurance company must complete your internal appeal within 30 days. If you’ve already received the service, the insurance company has 60 days to complete the internal appeal.
If the insurance company still denies your claim after it reviews your appeal, you can request an external review. In its final notice, the insurance company must give you instructions on how to make an external review request.
Make an external appeal
An external appeal lets you take the matter further by submitting your dispute to an organization that specializes in resolving health coverage disputes between parties. Depending on where you live, this could be either a state agency or a federally facilitated appeals entity that provides an external review.
Pay attention to time limits when it comes to this step, and submit your request for an external review promptly. You typically have to file a written request within four months of receiving a claim denial.
While filing an external appeal may feel intimidating, several federal and state laws protect your interests. Your state might have its own external review process. If it doesn’t, the Department of Health and Human Services will assist with your external review.
How long does an external review take?
You should receive a decision for a standard external review no later than 45 days after your request is received. If you’ve filed an expedited external review, you should receive a decision no later than 72 hours after the request was received.
Other consumer protections
Health insurance is complicated, but new protections are in place to help alleviate financial stress as of Jan. 1, 2022. For example, in an emergency, consumers are now protected against exorbitant costs if they’re out of network. Additionally, the Consolidated Appropriations Act of 2021 includes the No Surprises Act, which aims to create price transparency and avoid surprise costs. Because of the No Surprises Act, consumers can now submit disputes for external review when they get a medical bill that was more than expected.
Read More: The 10 Best & Worst Medicare Advantage Plans