How to appeal a denied medical insurance claim
You have the right to appeal, and that goes for Medicare or private health insurance.
PHILADELPHIA (WPVI) -- It's a question many consumers have asked themselves. If my health insurance refuses to cover a necessary test, treatment, or medication, what can I do?
Consumer Reports says you have a guaranteed right to appeal and it's not that hard to do.
About 18% of in-network claims from people insured through the Affordable Care Act were denied in 2020. But being denied does not mean you should immediately pay out of pocket or go without care. You have the right to appeal, and that goes for Medicare or private health insurance.
First, call your insurance company to make sure there wasn't a mistake with your claim.
"Mistakes can and do happen at multiple points in the claim filing pre-authorization process, and they can be relatively easy to fix," said Lisa Gill of Consumer Reports.
If that doesn't work, ask to speak to the reviewer behind the decision and request an explanation. You'll need that explanation for your next step, which is to file a formal appeal specifically stating that you disagree with the decision.
"You're going to ask your doctor to help to write a letter that explains the necessity for the procedure and include as many supporting documents as possible, like your medical records and treatment studies and any communication with the insurance company," said Gill.
Doctors are used to this, so don't be afraid to ask. The next step is to wait. It could take 30 days or longer for an answer. If you need the denied treatment right away, make sure you request an expedited review.
"So if you get a letter that the insurer is still choosing to deny the claim, know that both Medicare and the private insurance are required by law to give you the reason in writing and tell you how to appeal the decision with an independent third party," said Gill.
If you get your insurance through your employer, consider asking your company's human resources department to help.
If your claim was denied by Medicare, consider getting legal help to have your case heard before a judge.
