How to appeal a denied medical insurance claim

PHILADELPHIA (WPVI) — Many consumers have asked themselves this question. What do I do if my health insurance refuses to pay for a necessary test, treatment, or medication?

Consumer Reports says you have a guaranteed right to appeal, and it’s not that hard to do so.

About 18% of on-net claims from people covered by the Affordable Care Act were denied in 2020. However, a refusal does not mean that you should immediately pay out of pocket or give up care. You have the right to appeal, and that applies to Medicare or private health insurance.

First call your insurance company to make sure there is no error with your claim.

“Errors can and do occur at several points in the claims 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 will need this statement for your next step, which is to submit a formal appeal, specifically stating that you disagree with the decision.

“You will ask your doctor to help you write a letter explaining the need for the procedure and attaching as much supporting evidence as possible, such as your medical records and treatment studies and any communications with the insurance company,” Gil said.

Doctors are used to this, so don’t be afraid to ask. The next step is to wait. It may take 30 days or more before you receive a response. If you need the refused treatment immediately, make sure you request an expedited review.

“So if you get a letter that the insurer is still denying the claim, you should know that both Medicare and private insurance have a legal obligation to give you the reason in writing and let you know how to get the decision from an independent third party.” can contest,” Gil said.

If you buy your insurance through your employer, you should ask your company’s human resources department for help.

If Medicare has denied your claim, consider getting legal help to have your case heard by a judge.

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