If Your Health Insurance Claim Is Denied

It’s not unusual for insurers to deny some claims or say they won’t cover a test, procedure, or service that doctors order. You can appeal many types of health insurance decisions – sometimes even things that are written into your health plan’s contract. You can appeal Medicare claim denials, too.

Find out how long you have to file an internal appeal. If the insurer denies a claim, it must explain to you your right to appeal the decision. If you ask for it, they must give you all the information about the decision.

If your claim is denied, you might ask for more information from a customer service representative or case manager at your insurance company before you make a formal appeal.

Sometimes you can re-submit the claim with a copy of the denial letter and your doctor's explanation, along with any other written information that supports using the test or treatment that has been denied. Sometimes the test or service will only need to be “coded” differently.

Making a formal appeal

If questioning or challenging the denial in the ways suggested does not work, you may need to:

  • Request a written response. (Keep the originals of all the letters you get; your cancer team may be able to help you make copies if you need them.)
  • Keep a record of dates, names, and conversations you have about the denial.
  • Formally appeal the denial in writing, explaining why you think the claim should be paid. Your cancer care team members (doctor, nurse, social worker) may be able to help with this.
  • Get help from the consumer services division of your state insurance department or commission. (Contact information for the National Association of Insurance Commissioners is in the Additional resources footnote.)
  • Do not back down when trying to resolve the matter.
  • Consider legal action.
  • Find out if you live in one of the US states that also have a special Consumer Assistance Program (CAP) that can help you file an appeal. (You find out online at www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/. If you don’t live in a CAP state, get help from the consumer services division of your state insurance department or commission. Contact the National Association of Insurance Commissioners online or you can call them at 1-866-470-6242.

If your internal appeal is denied, you may be entitled to an independent external review by people outside your health plan.

Check with your insurance company about the process. For an urgent health situation, you may be able to ask for an external review at the same time you ask for an internal one.

You can also call the US Department of Health and Human Services contractor, MAXIMUS, at 1-877-549-8152 for information or an external review request form. You can also visit www.cms.gov/CCIIO/Programs-and-Initiatives/Consumer-Support-and-Information/csg-ext-appeals-facts.html to learn more about external appeals.

If you can't resolve your problem directly with the health plan

If all the internal and external appeals are exhausted, and the claim is still denied, ask the health care provider if the cost of the bill can be reduced. Many providers are willing to reduce bills to get paid faster. If all else fail, you might have to take your appeal to a higher level.

Private group plans (or fully insured plans) purchased from insurance carriers by employers as a benefit for employees are usually overseen by the insurance commissioner or department of insurance in each state. You can find your state’s insurance department by contacting the National Association of Insurance Commissioners.(See the Additional resources footnote.)

Self-funded plans (or self-insured plans) are health plans that employers or unions create just for their employees and their families. They are overseen by the US Department of Labor’s Employee Benefits Security Administration. Because employers often contract with insurance companies to administer these plans, it’s difficult to tell if a work-based plan is self-insured. You will have to ask your employer if your health plan is self-insured.

Individual plans sold through the health insurance marketplaces are regulated by a marketplace board in every state. This state board oversees the function of the marketplace and the plans sold within it. www.healthcare.gov

Managed care plans are regulated by several state and federal agencies. Your state insurance commissioner or department of insurance can provide specific information about an individual plan. www.naic.org/state_web_map.htm

Medigap policies (Medicare Supplement Insurance policies) are regulated by federal agencies, as well as some state laws. Contact the Centers for Medicare and Medicaid Services (CMS) and/or your state department of insurance for information. www.medicare.gov/supplements-other-insurance/how-to-compare-medigap-policies

Medicaid and CHIP are joint programs that are controlled by your state health department and the federal Centers for Medicare and Medicaid Services. www.medicaid.gov/chip/index.html

Medicare is run by the federal Centers for Medicare and Medicaid Services. www.cms.gov

TRICARE is overseen by the US Department of Defense. www.tricare.mil

The Veteran’s Health Administration is regulated by the US Department of Veteran’s Affairs. www.va.gov/health/

Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is run by the VA Chief Business Office Purchased Care. www.va.gov/communitycare/programs/dependents/champva/index.asp

The American Cancer Society medical and editorial content team

Our team is made up of doctors and oncology certified nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

Along with the American Cancer Society, other sources of information and support are listed below.

National Association of Insurance Commissioners
Toll-free Number: 1-866-470-6242
Website: https://naic.org/state_web_map.htmOffers contact information for your state insurance commission. You can contact your state insurance commission for insurance information specific to your state, or report problems with your insurance company

Medicare Rights Center (for those with Medicare)
Toll-free number: 1-800-333-4114
Website: www.medicarerights.org

This service can help you understand your rights and benefits, work through the Medicare system, and get quality care. They can also help you apply for programs that help reduce your costs for prescription drugs and medical care, and guide you through the appeals process if your Medicare prescription drug plan denies coverage for drugs you need

Patient Advocate Foundation (PAF)
Toll-free number: 1- 800-532-5274
Website: www.patientadvocate.org

Works with the patient and insurer, employer and/or creditors to resolve insurance, job retention and/or debt problems related to their diagnosis, with help from case managers, doctors, and attorneys. Typically for cancer patients in treatment or less than 6 months out of treatment.

National Association of Insurance Commissioners (NAIC) Map: states and jurisdiction for consumer reference links and insurance department contact information.  Accessed at https://naic.org/state_web_map.htm on May 3, 2019.

Tricare.  Medical necessity appeals.  Accessed at https://tricare.mil/ContactUs/FileComplaint/MedicalNecessity on May 3, 2019.

US Center for Medicare and Medicaid Services (CMS).  How to compare Medigap policies.  Accessed at https://www.medicare.gov/supplements-other-insurance/how-to-compare-medigap-policies on May 3, 2019.

US Center for Medicare and Medicaid Services (CMS).  State resources map.  Accessed at https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/AIAN/LTSS-TA-Center/info/state-resources-map.html on May 3, 2019.

US Center for Medicare and Medicaid Services (CMS).  The center for consumer information and insurance oversight: consumer assistance program (CAP).  Accessed at https://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/ on May 3, 2019.

US Center for Medicare and Medicaid Services (CMS).  The center for consumer information and insurance oversight: HHS-administered federal external review process for healthcare insurance coverage.  Accessed at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Consumer-Support-and-Information/csg-ext-appeals-facts.html on May 3, 2019.

US Department of Veterans Affairs (VA).  Board of veterans' appeals.  Accessed at https://www.bva.va.gov/CustomerService.asp on May 3, 2019.

Last Medical Review: May 13, 2019 Last Revised: May 13, 2019

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