How to Appeal a Denied Medical Claim in the U.S.

Receiving a denial for a medical claim can be frustrating, especially when you believe the service should be covered. However, patients in the U.S. have the right to appeal denied medical claims. By understanding the appeals process and taking the correct steps, you can challenge the decision and potentially receive coverage for your healthcare service.

Before starting an appeal, carefully read the Explanation of Benefits (EOB) or denial letter from your insurer. This document will detail why the claim was denied. Common reasons include lack of medical necessity, out-of-network care, incorrect coding, or missing documentation.

Knowing the specific reason is essential for crafting a strong appeal.

Review Your Policy: Start by reviewing your insurance plan documents. Understand what is covered, your responsibilities, and the deadlines for submitting an appeal.

Contact Your Insurer: Call your insurance company to get clarification on the denial. Sometimes, minor issues like missing information can be resolved without a formal appeal.

Gather Documentation: Collect all relevant records, including medical notes, test results, and referral letters. If possible, get a letter of medical necessity from your doctor explaining why the service was needed.

Write an Appeal Letter: Draft a clear, concise letter outlining why the denial should be overturned. Include your personal information, policy number, claim number, and a detailed explanation backed by documentation.

Submit the Appeal: Send your appeal by mail, online, or fax, depending on the insurer’s preferred method. Be sure to keep copies of everything you submit.

Follow Up: After submitting your appeal, follow up regularly to check on the status. Most insurers are required to respond within 30 to 60 days.

If your internal appeal is denied, you may be eligible for an external review by an independent third party. This option is mandated by the Affordable Care Act and allows you to challenge the denial outside your insurance company.

To initiate an external appeal:

Request an external review within four months of the final denial.

Complete the required forms provided by your insurer or state department of insurance.

Submit additional documentation supporting your case.

The decision made in an external appeal is binding on the insurer.

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Act Quickly: Don’t delay the appeal process. Most insurers have strict timelines for appeals.

Stay Organized: Keep a file with all documents, including letters, medical records, and notes from conversations.

Use Clear Language: Avoid jargon and explain your case in plain language.

Stay Persistent: If your appeal is denied, ask for clarification and consider moving to an external review.

Appealing a denied medical claim requires patience and diligence, but it’s a right that all policyholders have. By understanding your insurance policy, gathering strong documentation, and following the proper steps, you can improve your chances of overturning the denial. Remember, persistence and clear communication with your insurer are key to a successful appeal.