Health Insurance Appeals and Exception Requests
How to Appeal Health Insurance Denials
What To Know About Health Insurance Appeals
- Whether you buy your own healthcare policy or get coverage through a group plan provided by your employer, the Affordable Care Act gives you the right to appeal health insurance plan decisions.If you or your employer purchased your plan after March 23, 2010, your plan must give you a notice when it denies payment or rescinds your coverage that explains their reason, how you can appeal and any applicable deadlines. If you disagree with limits or denial of coverage, your appeal must be reviewed by your plan. If you still are not satisfied after the review, you will have the right to appeal that decision to an independent reviewer who is outside of the health plan.If you are in a health plan that you or your employer purchased before March 23, 2010 (when the Affordable Care Act was passed), you will need to check with your state insurance department, your employer and your health plan to find out whether you have similar appeal rights.
- You can appeal a plan’s decision not to pay for a benefit, or to reduce or end a covered service, when the plan says any of the following:
- The care is experimental or investigational.
- The care is not medically necessary or appropriate.
- You are not eligible for the health plan or benefit.
- You have a pre-existing condition.
The following are some examples of other health plan determinations or rules you can appeal:- Although the service, item or equipment prescribed by your doctor was covered by your health plan, the amount you were reimbursed is much lower than you anticipated or think is fair.
- Your health plan denies a request for pre-authorization for more sessions with your mental health provider.
- Your health plan does not cover a prescription drug your doctor has prescribed for you.
- Your health plan moves a covered prescription drug to a different tier, and your out-of-pocket costs will go up if you continue to take that drug.
- Your managed care health plan limits your use of healthcare professionals to in-network providers, but there is no provider in their network that specializes in the type of service you need.
- If you believe the service, device, treatment or medication in question should have been covered by your plan, you can and should appeal. Many people do not pursue their appeal rights because they don't believe they can win. But if you are dissatisfied with the outcome of a claim for any reason, you have nothing to lose by taking advantage of your right to request a re-consideration of the original claim.Follow these steps to appeal a decision:
- Look at your plan. Double check that what you presumed would be covered really is. It is not unusual for people to discover that a medical service or treatment is not covered by their policy. If something is specifically excluded from the policy, chances of winning coverage on appeal are slim to none. But if the policy does not mention the specific treatment in question — or the coverage is unclear or framed in terms of "medical necessity" — it is to your advantage to try the appeals process.
- Review your explanation of benefits. Carefully review the explanation of benefits (EOB) form your plan provider sent you. Make sure you understand the reason you have been denied coverage or why you are not being reimbursed more money. These explanations often appear as codes with explanatory notes at the bottom or on the back of the form.
- Look at your plan’s appeal procedures. If your EOB seems in order, read your plan's appeal procedures. Look in your manual (sometimes under "Grievances and Appeals"). Follow the procedures carefully and pay special attention to the deadlines.
appeal letter templates for healthcare providers available on our website. - Provide copies of your appeal letter to your healthcare provider for their records. Make sure you do not duplicate efforts.
- Follow up. If your appeal is denied, go to the next level of appeal. Do not assume this happens automatically — make sure you communicate your desire for a second-level or external review. This will be a re-consideration of your original claim by professionals with no connection to your insurance plan. If the external reviewers think your plan should cover your claim, your health plan must cover it.
- Keep detailed records. Track all interactions with your insurer, including names of company representatives you speak with on the phone and relevant dates. Keep copies of claims and bills, appeal letters and any attachments and any other relevant communications.
- Write a very clear and simple letter. Your appeal should provide the facts and a concise explanation of why you believe your claim should be paid. Keep your letter to one page, but be sure to include your insurance ID number, the specific claim number (if applicable), the name and contact information of your healthcare provider and date of service (if applicable).
- Discuss your appeal with your physician. Tell your healthcare provider about your insurer's denial, or other coverage issues you are appealing, to get their active support. If the dispute is over the necessity or value of a medical treatment, your physician's support could be very valuable. They can supply a letter including studies supporting the benefit of the treatment in question. There are appeal letter templates for healthcare providers available on our website.
- Provide copies of your appeal letter to your healthcare provider for their records. Make sure you do not duplicate efforts.
- Follow up. If your appeal is denied, go to the next level of appeal. Do not assume this happens automatically — make sure you communicate your desire for a second-level or external review. This will be a re-consideration of your original claim by professionals with no connection to your insurance plan. If the external reviewers think your plan should cover your claim, your health plan must cover it.
- Keep detailed records. Track all interactions with your insurer, including names of company representatives you speak with on the phone and relevant dates. Keep copies of claims and bills, appeal letters and any attachments and any other relevant communications.
- Write a very clear and simple letter. Your appeal should provide the facts and a concise explanation of why you believe your claim should be paid. Keep your letter to one page, but be sure to include your insurance ID number, the specific claim number (if applicable), the name and contact information of your healthcare provider and date of service (if applicable).