Living with Chronic Pain

Appealing Insurance Coverage Denials

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The purpose of medical insurance coverage is to provide financial assistance for health care. Unfortunately, insurance companies do not always cover physician-recommended treatment. When this happens, the insured has the right to appeal the denial of coverage.

A health insurance policy is a contract between a person(s) and an insurance company regarding financial coverage for health care services. Prescription drug insurance is sometimes included under the same plan; more often, it is covered under a different plan from a different company.

Depending on specific coverage details of a health insurance policy, pre-authorization for medical visits and/or treatment can be required. Make sure to review the plan, and call the insurance company with any questions.

Even if an insurance company does not require pre-authorization, they can deny coverage for several reasons, such as: policy coverage limitations, surpassing the benefit amount for the year, and health care they deem optional, exploratory or unnecessary. In such situations, an insurance claim denial letter is sent to the individual. Claim denials can be appealed to reassess or review any decision made by the insurance company.

When to appeal

When considering an appeal on a denial of a claim, the first step is to thoroughly read and understand the reason for the claim denial. Sometimes, a claim is denied simply because the insurance company needs additional information from the individual or the health care provider. When a physician orders a required treatment, procedure or device to obtain or maintain optimal health, and the insurance company denies the claim, an appeal should be considered.

How to appeal

Information about how to appeal a denied claim should be included with the denial letter from the insurance company. Follow the instructions precisely. To make a more substantial case, do the following:

  • Include a letter from the attending physician explaining why the treatment, procedure, or device was required.
  • Contact the Consumer Assistance Program in the state where the claim was filed or contact the state’s insurance commissioner’s office for help completing the process of an appeal.
  • What to do if an appeal is denied

    If an appeal is denied, then an external review can be requested. An appeal is done internally; whereas, an external review employs an independent person outside of the insurance company to review the appeal and denial.

    A request for an external review can be completed the following ways within 60 days of receiving the appeal denial letter:

  • Send a request in writing to the insurance company asking for an external review.
  • Ask the attending health care professional to submit a request for an external review of the appeal and denial.
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