My Health Claim Was Denied; Now What? Part 3: Maximizing the Chances of a Successful Appeal

When appealing a health insurance claim denial, it can feel overwhelming. The various steps in the process are time consuming and can be confusing. However, when disputing a denied claim, these simple but effective strategies may help you take control of the appeals process and improve your chances of a favorable outcome.

Submit the Right Paperwork

There are often several ways to initiate the appeals process, but the most efficient way is to follow your insurance company’s standard procedure. The Explanation of Benefits or denial letter you received should tell you how to appeal the decision. You can also call your insurance company directly to find out the steps you need to take. Always try to obtain your appeal rights and the necessary steps in writing.

If you are appealing an insurance denial for a loved one, you will need to fill out an Authorized Representative Form, or similar document, along with the appeal form. If you need to write a letter to your insurance company, make sure to include your claim number and the number on your health insurance card.

Organization Is Key

The insurance company has its own internal system for tracking your medical claim and any subsequent appeals. You must be just as organized to make sure you’re following up on any detail that may make the difference.

  • Keep all your paperwork in one place and take careful notes during every phone call with the insurance company.
  • Ask for the name and job title of the person you’re speaking to, and write down the date of the conversation and any next steps you need to take.
  • Get your “call reference number,” and if an appeal was submitted, get the “document image number.”

This information will help you build your case and ensure that the next customer service agent you speak to can quickly access all the necessary files to help you move the appeal process forward.

Remember the Timeline

The timeframes set out in your insurance policy are critical. If not followed to the letter, you may be at risk of losing your appeal altogether.

Set up a system to remind yourself to follow through. If a customer service agent tells you he is going to resubmit your claim and it will take about a week to be processed, make a note in your calendar to call back in a week to check the status.

Never be afraid to check on the status of your claim or appeal. The company is more likely to move your claim through the pipeline if you apply a little gentle pressure.

Don’t Shoot the Messenger

Having a claim denied is scary. If you’re waiting for pre-approval before you can have tests or a necessary procedure, it can be even worse. But don’t forget the person on the other end of the phone is probably not the person responsible for denying your claim. She might be a valuable ally, so treat her with courtesy and respect.

If you find yourself getting upset, explain that you’re very concerned about your case but you know it’s not her fault. Try your best to always be courteous, patient and detailed in your conversations with representatives.

Take It to the Next Level

The first level of the appeals process is conducted directly with your insurance company. If your claim is denied by the insurer a second time, you may still have options.

The Affordable Care Act requires that states set up an external review process for denied medical claims. During the external review, an independent third party examines the many details of your claim and the reasons the insurance company denied it. The external reviewer will either uphold or overturn the insurance company’s decision to deny your claim. By law, the insurance company must accept and abide by the external reviewer’s decision.

Speed Things Up

If you need medical care urgently, you may not be able to wait for the company’s internal appeals process to run its course. Says

“You can file an expedited appeal if the timeline for the standard appeal process would seriously jeopardize your life or your ability to regain maximum function.”

In such cases, file internal and external appeals simultaneously. If you’re too sick to take care of this on your own, your doctor can file an external appeal on your behalf.

Consult an Attorney

A favorable outcome to your health insurance dispute can help you and your family avoid financial challenges, emotional turmoil and painful medical conditions. With so much riding on a positive ending, retaining an experienced attorney may be your best course of action.

Our St. Paul health insurance dispute attorneys provide hands-on guidance throughout Internal and External claims appeals. We work diligently to help you state your case for coverage and hold the insurance company to their end of the bargain. Call (651) 788-0236 or contact our firm online today.


Disclaimer: The information in this blog post (“post”) is provided for general informational purposes only, and may not reflect the current law in your jurisdiction. No information contained in this post should be construed as legal advice from Wrobel & Smith, PLLP or the individual author, nor is an attorney client relationship established. This post is not intended to be a substitute for legal counsel on any subject matter. No reader of this post should act or refrain from acting on the basis of any information included in, or accessible through, this Post without seeking the appropriate legal or other professional advice on the particular facts and circumstances at issue from a lawyer licensed in the recipient’s state, country or other appropriate licensing jurisdiction.



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