What to do when your insurance claim is denied? A high-level overview of the appeal process.

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Imagine opening your mail to find a surprise bill from a medical provider due to a denied claim. Now imagine that preauthorization for your child’s lifesaving procedure was denied. These are not situations that students, or anyone else, should have to worry about. A denial from the insurance company can be disheartening, but there are steps that can be taken to appeal the decision. Below is a high-level overview of the process for appealing an insurance claim.

  1. Do your research

An Explanation of Benefits (EOB) and insurance Policy/Brochure are good resources to review when trying to understand why a claim was denied. If a student has reason to believe that the claim was misclassified or not paid according to the benefits policy, then they have a good reason to appeal. This information will help them to have a solid argument as to why their claim should be paid.

  • Contact the insurance company immediately

After they have completed their research, students should contact the insurance company. The phone number can be found on the back of the ID card. The representative should be able to give more detail as to how the claim was paid, however, they likely will not be able to change the status of the claim without sending it for a secondary review by a Claims Specialist.

  • Contact the medical provider
    Claims are paid based on the procedure and diagnosis code sent over by the provider’s office. If it is believed a claim was denied due to an incorrect billing code or incorrect patient data, call the provider’s office to resubmit the claim to the insurance company with the correct information.
  • Internal Review

If the issue is not resolved using the steps above, then it is time to begin the formal process. Under the Affordable Care Act (ACA), you have the legal right to ask for an internal review. If this appeal is denied, you have the legal right to ask for an independent, external review.

Non-urgent internal reviews require a written letter be submitted with 180 days from the receipt of denial. The Explanation of Benefits should provide instructions on where to send the internal appeal. There are specific items which should be included in the letter including the patient name, policy information, and strong arguments and supporting evidence as to why the plan should cover the claim such as a letter of medical necessity submitted by a medical professional.

  • External Review

Claims that have been denied due lack of medical necessity or because the service is experimental or investigational can be sent for external review. External reviews occur at the State or Federal level, depending on whether the States process is deemed compliant. Plans in Texas have been required to use the Federal External review process since June 30, 2018.

Complaints at the State level are handled by either the Department of Insurance or the state Department of Health, while Federal external reviews are handled by an accredited Independent Review Organization (IRO) contracting process or the U.S. Departments of Health and Human Services (HHS).

We can’t promise the appeals process will be easy, especially if an external review is required, but we urge you to be persistent and to never give up. Depending on the situation, legal support may be required, and a Student Assistance Program could be a good avenue for students to access legal resources.