Denied Claims vs. Rejected Claims
A health insurance claim denial occurs when an insurance company does not approve payment for a specific claim. The health insurer decides not to pay for a procedure, test, or prescription. A rejected claim can be easy to correct. This is a claim that’s not processed because incorrect information has been submitted with the health insurance claim form. Rejected claims don’t have to be appealed. You can simply correct the error. Resubmit the right information and your insurance company should begin to process the claim.
5 Reasons Why a Health Insurance Claim Could Be Denied
Knowing why your health insurance claim was denied is key because it tells you whether you can appeal the decision. If your appeal succeeds, the company must pay for the claim even though it was denied at first. Health insurance claims are denied for five common reasons:
How To Fight a Health Insurance Claim Decision
You’ll receive a denial notice if your health insurance claim is denied. The notice should tell you how long you have to appeal the decision. It is crucial that you do not miss the deadline. Find out why your claim was denied before you begin the appeal. Appeals won’t always make sense if your plan clearly states that the service you need isn’t covered, you were out of network, or you’ve maxed out your coverage limit for the year. Review your insurer’s website if you’re not sure. You can also call to better understand your health insurance policy coverage and the reason for your claim denial.
Write an Appeal Letter To Fight a Claim Denial
Writing an appeal letter for your denied health insurance claim is a matter of sharing the proper information so you can have your case looked at as soon as possible. The insurance company may find it hard to review your appeal if you request one but can’t explain why your claim was denied. Follow the appeal procedure exactly as it’s outlined to avoid delays. Doublecheck it before you send it. You want the requested information to go to the right department or person.
What Your Appeal Letter Should Include
A health insurance claim denial can frustrate you to tears but keep the emotion out of it. A simple letter that gets straight to the point is the best approach. Your appeal letter should be “matter of fact” in tone. Include any information that your insurance company tells you is needed and be sure to thoroughly explain why you need the treatment you were denied. Here are the sections to include in your appeal letter.
Opening Statement
State why you’re writing and what service, treatment, or therapy was denied. Include the reason for the denial. Your intro can state: “I am writing about Claim Number 123456ABC. I received a letter denying my claim for XYZ services for this reason: ______________. I would like to appeal this decision.”
Explain Your Health Condition
Outline your medical history and health problems. Explain why you need the treatment and why you believe it’s medically necessary. List any treatments you’ve already tried. Explain why you believe that the current treatment may be a solution.
Get a Doctor To Support You
You’ll need a doctor’s note. Ask your physician to support you with information that verifies your statements about your health and the treatment. Provide documentation from recognized institutions, such as hospitals and medical schools, that shows it as part of a recognized treatment plan if the treatment is new. Send your appeal on time by certified mail. You’ll want proof that you submitted your request within the time limit. Keep records of all emails showing the time it was sent if appeals are only accepted online. The key is to understand your coverage and why your claim was denied when you’re looking to appeal a health insurance claim denial.
