How to File a Health Insurance Appeal for a Denied Claim: What Patients Need to Know
If Your Insurance Provider Denies a Claim, You Have the Right to File an Appeal
When you receive medical services, your medical provider will submit a request for payment for those services to your health insurance provider (called a claim). Your insurance provider might deny all or partial coverage of the claim. If this happens, you can file an appeal. An appeal is a request to review a health insurance provider’s decision regarding a claim. The process of filing an appeal can seem daunting. But it is both your right and in your best interest to appeal a denied claim that you and your healthcare team deem important for your health.
In 2019, 40.4 million health insurance claims were denied and only .02% of those denied claims were appealed (Pollitz, 2021). This equates to only 63,318 appeals of 40.4 million denied claims. Yet, people who do file an appeal often see results in their favor: “It is absolutely in somebody’s best interest to try and appeal, because we know somewhere between 40% and 60% of all appeals are decided in favor of the patient,” notes Monica Bryant of Triage Cancer.
This blog offers tools, advice, and guidance to empower patients who need to file a health insurance appeal for a denied claim.
It is both your right and in your best interest to appeal a denied claim that you and your healthcare team deem important for your health.
Before filing an appeal, it is helpful to understand the different types of insurance appeals:
- Internal appeals
- External appeals
- Expedited appeals
An internal appeal is where you go back to your insurance company (individual or funded plan) or your employer (self-funded plan) and ask them to reconsider their decision. Appeals can take place after you received a service or before you receive a service. You have 6 months (180 days) from the day you learn your claim was denied to file an appeal. Your insurance company then has a set timeline to respond back. You can also file an expedited appeal, for example, if waiting for an extended period of time could cause more harm.
An external appeal can be filed if your insurance denies your original appeal. In this case, you go to an independent entity and ask them to look at the facts. This process is based on your state’s specific laws, and the decision at this step is final in all cases. Generally, you have 4 months from the day you learn your claim was denied to file an external appeal. You can also file an expedited appeal, if you qualify.
An expedited appeal is useful when the time needed for a standard appeal could harm your health. With this type of appeal, you can file both internally and externally at the same time, if the case permits.
Prepare to File an Appeal
Step 1: Determine the type of plan you have.
Knowing what type of insurance plan you have will help inform the steps you will take when you file an appeal. Types of plans include:
- Individual plan: This plan is purchased through a state’s marketplace or directly from an insurance company.
- Funded plan: The employer purchases an insurance plan from an insurance company and the insurance company covers medical expenses.
- Self-funded plan: Your employer pays directly for your healthcare costs. Often in this case, employers will hire an insurance company to administer the plan.
- Medicare: Call 800-MEDICARE (800-633-4227) for free appeal assistance, or contact your State Health Insurance Program provider.
- Medicaid: Contact your state’s Medicaid agency.
Need help determining what type of health insurance plan you have? Triage Cancer provides a questionnaire to help you identify your plan. Or, contact your state’s Department of Insurance to find out what kind of plan you have.
Step 2: Understand the reason for a denial.
Here are some examples that may explain why your claim was denied. There may be other reasons not listed here.
- Administrative: Wrong coding
- Experimental or investigational: Off-label drug use
- Not eligible for the service or benefit under your health plan
- Not a covered benefit: Cosmetic surgery
Step 3: Gather evidence to prove that the treatment or service is medically necessary.
Work with your medical team to illustrate the need for the treatment or service. This can include a letter from your provider, your medical records, and medical literature to support the medical effectiveness for a specific treatment.
Tip 1: When filing an appeal, use a spreadsheet or form to keep track of all your correspondences. This will help keep you aware of what has been completed and what needs to be done.
Tip 2: Organize all correspondences, notes, copies, and records in one place so that you can quickly reference information about your appeal.
Get Help With the Appeals Process
If you receive a health insurance claim denial, you can contact your state’s Department of Insurance to help point you in the right direction. They can let you know who you can reach out to for assistance with filing your appeal. Find the contact information for your state’s Department of Insurance.
“The people who staff Departments of Insurance have a great deal of knowledge, and they want to share it with you and they want to help you.”
— Mary Kwei, Maryland Insurance Administration
State Departments of Insurance are also the entities that typically conduct external reviews, should you have to file an external appeal. They may also be able to help you determine if your appeal is eligible for an expedited process.
Get Help With Your Health Insurance Questions
We are here to support you. If you have questions about health insurance or other concerns about the cost of cancer care, we can help. Call our Cancer Support Helpline at 888-793-9355 to talk with an experienced patient navigator.
“We want the patient to know that they are not alone in this process."
— Aimee Hoch, Financial Navigator, Cancer Support Helpline
Editor's note: On April 25, our Cancer Policy Institute hosted “Health Insurance Appeals 101,” a webinar about the insurance appeals process. This webinar was part of our Forum on Utilization Management, which was created to bring patient advocates together for meaningful conversations, ask tough and nuanced questions, and identify new ideas and practices that optimize evidence-based healthcare. Speakers Monica Bryant of Triage Cancer, Mary Kwei of the Maryland Insurance Administration, and Aimee Hoch of the Cancer Support Community spoke about what patients and caregivers should know about the insurance appeals process. Monica, Mary, and Aimee highlighted resources that will assist in filing an insurance appeal.
Pollitz, K., McDermott, D. (2021). Claims Denials and Appeals in ACA Marketplace Plans. Kaiser Family Foundation.