How to appeal a denied medical insurance claim

What do you do if your health insurance provider refuses to cover a test, treatment, or medication your doctor says you need? 

Before you dig into savings and pay out of pocket, Consumer Reports says you have a guaranteed right to appeal. 

And the good news is that it’s not that hard to do.

According to a report from Kaiser Family Foundation, about 18 percent of in-network claims from people insured through an Affordable Care Act plan were denied in 2020.

But that doesn’t mean you should immediately pay for the treatment yourself, or worse, go without care. 

Consumer Reports says you have the right to appeal the decision, and that goes for Medicare or private health insurance.

Step one: Call your insurance company to make sure there wasn’t an error with your claim. 

Mistakes can and do happen at multiple points in the claim filing or pre-authorization process, and they’re often relatively easy to fix once you identify them.

If there isn’t a mistake, ask to speak to the reviewer behind the decision and request an explanation. 

You’ll need this information for your next step: filing a formal appeal specifically stating that you disagree with the decision.

Ask your doctor to write a letter that explains the necessity for the procedure. 

They’re used to this, so don’t be afraid to ask. 

And gather copies of as many other supporting documents as possible, like your medical records, treatment studies, and any previous communication with the insurance company. 

The next step might be the hardest: Waiting. 

It could take 30 days or longer for an answer, but if you need the denied treatment right away, make sure you request an expedited review.

If you get a letter saying that the insurer is still choosing to deny the claim, both Medicare and private insurance companies are required by law to give you the reason in writing and tell you how to appeal the decision for review by an independent third party.

If you get your insurance through your employer, consider asking your company’s human resources department to help. 

If your claim was denied by Medicare, you can consider getting legal help to have your case heard before a judge.

All Consumer Reports material Copyright 2022 Consumer Reports, Inc. ALL RIGHTS RESERVED. Consumer Reports is a not-for-profit organization which accepts no advertising. It has no commercial relationship with any advertiser or sponsor on this site. Fo