How to Appeal an Insurance Denial 

How to Appeal an Insurance Denial

Introduction
When an insurer denies a claim for medical services, supplies or prescriptions, patients have the right to file an appeal to request reconsideration of the decision. Under the 2010 Affordable Care Act (ACA), all insurers, including Medicare, are required to have an appeals process in place. Patients may file an appeal if an insurer:

  • Denies a request for coverage or payment of a health care service, supply or prescription that a patient thinks he should be able to get;
  • Denies payment for a health care service, supply, or prescription that a patient has already received;
  • Changes the amount a patient is requested to pay for a prescription; or
  • Stops covering or paying for part or all of a health care service, supply, or prescription that was covered/paid for previously.

How to Appeal an Insurance Denial

  • Find the reason for the denial by reading the Explanation of Benefits or Medicare Summary Notice the insurer provides.

    Under the ACA, when insurers deny a claim, they are required to tell you why the claim was denied, how to appeal the denial, how to request an external review, and the availability of a Consumer Assistance Program to assist with the appeals process.
  • Review insurer’s coverage policies (usually found online) to make sure that the denied service, supply, or prescription is eligible for coverage.
  • Determine the insurer’s appeals process (varies by insurer).
  • Submit formal appeal within necessary timeframe as detailed in the appeals process (varies by insurer).
  • Keep notes, including names of individuals spoken to, or any phone/email conversations.
  • Keep copies of all appeals and supporting information provided to the insurer.
  • Under the ACA, insurers must respond to an appeal within 72 hours of receipt for urgent care, within 30 days of receipt for services, supplies, or prescriptions not yet received, and within 60 days of receipt for services, supplies, or prescriptions already received.
  • If the insurer continues to deny the claim, a patient may request an external appeal (the process varies by state law), in which an independent third-party will review the claim and make a final, binding decision.

Medicare Appeals
For Medicare beneficiaries, the Medicare Summary Notice (MSN) will provide details on filing an appeal. Appeals under Original Medicare plans must be filed within 120 days of receiving the MSN. Typically Medicare contractors will reply in writing within 60 days of receiving an appeal. If you are covered by Medicare, there is detailed appeals information on www.medicare.gov.

Helpful Tips
Your physician may be able to help you appeal by writing a letter on your behalf, explaining the medical necessity of the service, supply, or prescription that insurance denied.

If your health plan is an employer self-funded plan, there are additional appeals processes available. Contact your employer’s human resources department for more detailed information.

Patients who do not speak English may be entitled to receive appeals information in their native language upon request beginning January 1, 2012.

Resources
Patient Advocate Foundation
Medicare Beneficiary Homepage
Administration on Aging
American Association of Retired Persons
State Consumer Assistance Programs

Allison Waxler, Senior Manager of Health Policy & Practice
Reviewed by NASS Patient Education Committee