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 below.)
• 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/index. 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.

It helps to know who regulates a health plan if you have a problem that you can’t resolve directly with them. You can talk to the government group that regulates the health plan to find out if they can offer more information or extra help.

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

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