Where to Start if Insurance Has Denied Your Service and Will Not Pay

If your insurance plan refuses to approve or pay for a medical claim, including tests, procedures or specific care ordered by your doctor, you have guaranteed rights to appeal. These rights were expanded as a result of the Affordable Care Act.

Review your denial letter carefully as it outlines your next steps for appealing their decision.

Your insurer must provide to you in writing:

  • Information on your right to file an appeal
  • The specific reason your claim or coverage request was denied
  • Detailed instructions on submission requirements
  • Key deadlines to submit your appeal
  • The availability of a Consumer Assistance program, if available in your state

Reasons that your insurance may not approve a request or deny payment:

  • Services are deemed not medically necessary
  • Services are no longer appropriate in a specific health care setting or level of care
  • The effectiveness of the medical treatment has not been proven
  • You are not eligible for the benefit requested under your health plan
  • Services are considered experimental or investigational for your condition
  • The claim was not filed in a timely manner

Think of an appeal as a contract dispute over the interpretation of the plan coverage details. Your health plan language defines your contract.

It is important to remember, that prior authorization does not guarantee payment of the claim.

There are multiple levels of appeal. Even if the first appeal is denied, you have additional levels of appeals that will be outlined in your denial documents. To learn more about the appeals process, watch our free training series: Health Insurance Denials and Appeals, Don’t Take No for an Answer or read our guide Engaging with Insurers: Appealing a Denial.

*If you have overdue medical bills on services that have already been completed, work with your providers so the bill is not sent to collections while the appeals process takes place.

FAST FACT: Your health plan cannot drop your coverage or raise your rates because you ask them to reconsider a denial related to care.

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