Health Insurance Claim Denied, What's Next?

Many Americans submit health insurance claims and eagerly await the benefits they need to cover their medical expenses. Unfortunately, many people get their health insurance claims denied. It happens more often than you would think. 

Do not assume that health insurance companies want to approve every claim. While some denials are legitimate, more often than not, health insurance companies scrutinize policyholders excessively to find reasons for denial on the first claims submission.  

For many, after a denial, it may seem like there is no course of action to take, but the good news is that there is. You can appeal the decision and continue to fight to receive fair compensation for your medical damages. If you find yourself stuck at any point during the appeals process, you can always seek legal help to get you through any roadblocks. 

Why Was Your Health Insurance Claim Denied?

There are many reasons why your health insurance claim was denied. It is impossible to know the exact reason without first examining your case, but typically, health insurance claims are denied due to the following: 

• You received services that are not covered by your health insurance. 
• You file your claim past the deadline stated for coverage. 
• You received medical services that required pre-authorization to obtain, or you received services from an out-of-network provider. 
• The service you received is deemed “not medically necessary” by the insurance company. 
• The insurance company may use a “step therapy” model, meaning they escalate treatment based on your needs. If you got treatment out of order from this model, they will likely refuse to cover it. 

Health insurance denial rates vary. Some health insurance companies deny coverage less than others. It will all depend on your unique case. 

Immediate Steps You Can Take After a Health Insurance Claim Denial

After your claim gets denied, there are several actions you can take immediately to start laying the groundwork for your appeal. 

Contact Your Insurance Provider

Once you get your denial notice, it is important that you reach out to your health insurance provider for more details. While the notice should have all of the information you need, many times, there are critical details that get omitted. Nevertheless, contacting your insurance company and asking for the complete details surrounding your denial and confirming information regarding your claim is critical for the success of your appeal. 

Review Your Policy or Explanation of Benefits (EOB)

Before you file an appeal, you should obtain a copy of your policy or explanation of benefits (EOB). Within your policy or EOB, there should be a complete set of guidelines for what gets covered through your insurance and what does not. 

From there, you can figure out any gaps or lapses in coverage that do not accurately reflect your denied claim and potentially build a case around that for your appeal. Even if you feel like you know your policy inside and out, there may have been something you missed that you will need to prove in your claim. You should always double-check and make sure. 

Gather Medical Records and Supporting Documents

Gathering your medical records and supporting documents as soon as possible is critical. It is easy to misplace valuable evidence that can support your appeal. Thus, after the insurance company denies your claim, you should collect as much evidence as possible to make the appeal process easier. 

Remember, evidence may seem like it lasts forever, but as time passes, it becomes harder and harder to make an appeal. Taking prompt action to retain and organize all of your crucial evidence is very important. 

How to File an Appeal After a Health Insurance Claim Denial

Remember, as mentioned previously, you have the right to file an appeal for a denied claim. Never walk away from a denied claim thinking there is nothing you can do about it. There are two ways to file an appeal:

• Internally with the Insurance Company - Each insurance company will have its own appeal process. Generally, you request an appeal and submit your case in writing with all the evidence needed to support your claim, and then, after a thorough review, a final decision will be made. 
• External Review with a Third Party - Instead of taking up your appeal with the insurance company directly, you can get an external third party to make the final decision. It works the same as an internal appeal, but instead, a neutral third party will essentially arbitrate. 

How you choose to file an appeal is entirely up to you. Generally speaking, internal appeals with the insurance company directly usually have a faster turnaround time than external reviews. There are pros and cons to either method. A qualified professional or advisor can help you better understand your rights and available options.

What to Do if Your Appeal Was Also Denied

This primarily applies to those who get their internal appeal denied. If the insurance company decides to reject your appeal, you will likely need to file an external review with a third party. If you have not already, it would also be in your best interest to get in touch with a lawyer to review all available options for your case.  

Additionally, if you feel that your claim was unjustly denied, you can file a complaint with your state’s insurance commissioner’s office and any other relevant regulatory agencies. Doing so may give you a chance to reverse your denied appeal. In this instance, it is wise to get professional legal assistance to ensure everything goes smoothly. 

When Should You Talk to a Health Insurance Dispute Lawyer

You may consider consulting a health insurance claim denial attorney to better understand your options and ensure your appeal is handled properly.. Even though you can file a claim on your own, it is wise not to do this, as the insurance company likely will not make it easy for you to appeal your claim and will try to get away with paying you only the bare minimum or nothing at all. 

At the end of the day, insurance companies are businesses. Insurance companies review claims according to their internal policies and procedures, which can sometimes result in lower reimbursements than expected. The appeal process may seem straightforward, but insurance companies follow complex procedures and may apply strict interpretations of their policies, which can make the appeals process challenging.

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This article was provided by a third party as part of a commercial collaboration. The views expressed are solely those of the author.

Antoine Fruchard

Insurance expert

Co-founder of HelloSafe and an experienced entrepreneur in the insurance and personal finance sector, Antoine uses his experience and in-depth knowledge of the market to help Internet users make the right choices. With an MBA in economics, he is a committed expert whose mission is to make personal finance and insurance issues simple and understandable. With a rich career marked by the creation of innovative companies, Antoine's ambition has always been to bring transparency to complex issues and to give power back to consumers. With HelloSafe, he continues to translate this vision by providing accurate advice, impartial comparisons and detailed explanations of travel insurance. He has analysed hundreds of contracts to reveal the best options available on the market.