Health Insurance 101: How to Appeal Claim Denials and Get Coverage

Did your insurance reject a claim? Here’s how to appeal the decision.

Loading the player...

It’s easy to panic when your health insurance company rejects a claim. After all, a rejected claim generally means you might need to foot the bill yourself. To make it worse, you might disagree with their decision. What many people don’t realize is that you can appeal a claim denial and potentially get insurance coverage.

What Is a Claim Denial?

When you get a healthcare service, supply, or medication, your provider will send a claim to your insurer. This is basically a request to the insurer for payment, similar to an invoice. The claim states what health service you received and how much it costs. Learn more about what an insurance claim is here.

Your insurance company will then approve or deny the claim. If they approve it, that means they agree to cover the cost (partially or fully). Depending on your plan, the service, and other factors, you may still owe some money (such as a coinsurance).

A claim denial means that the insurance company has decided not to cover a medical expense. If the insurer denies the claim, you may then have to pay full price for the service. This may happen if:

  • Your plan doesn't cover that specific service or treatment
  • The insurer does not deem the service "medically necessary"
  • You received prior approval for the service, but you did not receive the service within the designated time limit

How to Appeal an Insurance Claim Denial

If you think your insurance company made a mistake, you can appeal their claim denial. This basically means asking the insurer to reconsider their decision and providing more information to support your stance.

An Internal Appeal

You usually start with an internal appeal, which means the insurance company itself will re-review the rejection. This must be done within six months of the initial denial, although it may vary depending on your exact company. Your insurer’s website will likely have a page for forms where you can find the paperwork to start the appeal process.

You’ll fill out the forms provided by your insurance and then include any evidence that may help change their decision. A common option is a letter from your doctor. For example, if the claim was rejected because the service wasn’t deemed “medically necessary,” your doctor can write to defend why the service was actually necessary.

After the review, the insurer may decide to change their decision and approve the claim. On the other hand, they might stick to their stance and reject the appeal. They are required to tell you the reasons for the rejection.

An External Review

At this point, you might consider filing for an external review. This is when an independent third-party reviewer will examine the appeal. Whatever the external reviewer decides is the final call, and the insurer must follow the decision.

Moral of the story: A claim denial isn’t always the end of the road. You can speak up if you think your insurer made the wrong call, and there’s a system in place to help you advocate for yourself. Call a representative for help if you’re not sure how to file an appeal with your insurer.