How to Appeal a Denial of Coverage from your Medical Insurer

When an insurance provider refuses to cover a certain treatment, this can become a time consuming battle. It can cause a lot of aggravation and people who are ill don’t really need this kind of stress. It is worth it sometimes to appeal their decision and there are strategies you can employ to assist you in putting forward your case.

Some problems with getting a claim approved can be simple, such as a doctor putting down the wrong code on an insurance form. This type of issue can be overcome with a simple phone call. But, there are some insurance problems that will take more than a phone call to resolve. It could be that a certain cancer treatment is under fire by your insurance provider and it could be detrimental to your health to not appeal the decision.

Finding out the reasons why coverage was denied and learning the insurance companies procedure for appeals is your first step. Whenever you call your insurance provider to get information, take notes. Write down who you spoke with and ask for documentation about the rejection of the claim. This is important as it could turn out the problem is easy to resolve.

You will need a copy of your insurance plan’s full benefits or the “Evidence of Coverage” as well as the letter of denial, which should state the reasons your claim was rejected. You should also ask for detailed guidelines that explain what the company considers medically necessary. Some insurance providers will post their policies regarding medical insurance online, on their website. Under the Affordable Care Act (ACA) 2010 when an insurer denies coverage, they must tell you why it was denied, how to appeal the decision, how to request an external review and they must tell you about the availability of Consumer Assistance Programs to assist with the appeal.

Once you have all of this information, plot a strategy. You can begin by getting advice from the non-profit agencies that offer free advice. You can also find an insurance advocate. Many states have health insurance advocates and these people might even be able to intervene on your behalf. The advocacy group Families USA offers a list of state resources. Another resource that may help you is the nonprofit Patient Advocate Foundation; this organization deals with appeals regarding health insurance denials at no cost.

Your appeal may require you to prove your treatment qualifies under your health insurance policy, in addition to the plan’s benefits and rules. You will need to analyze the language within your policy. Moreover, try to figure out why the treatment you have asked the policy to cover fits into a category of care that the insurer has promised to pay for.

Medical insurance appeals circle around different issues such as whether a treatment is scientifically proven effective and medically necessary in the patient’s case. Your doctor can be an invaluable ally in this situation, and may be able to write a letter on your behalf. You may be able to bolster your case by doing some research about your procedure. Anything you find related to your treatment in a reputed medical journal might turn out to be strong evidence. Report what you have found to your doctor so that he or she can explain anything that you do not understand. At the same time, there might be information within your research that can be put in the letter to your insurer.

If your insurer rejects you appeal, then there are still other options. You can choose to appeal through the state using the state’s insurance regulator. If this is not an option for you, then they will be able to advise you on what to do next. There are different rules in every state, and out of the 44 states that offer independent reviews, some will not handle all kinds of issues. For Medicare benefits, there is a federal appeals process that you can learn about at:

So, remember to find out why the insurer has rejected your claim, get all of the documentation together and ensure you have a paper trail. Be prepared to prove that your treatment does qualify for coverage under your insurance policy. Lastly, most states will consider appeals as a last resort only and not all situations qualify.