If you disagree with your health insurer’s decision to not cover a service, you have the right to appeal this decision. Many appeals are approved. Some appeals are handled by your healthcare provider, but you can also appeal a decision yourself.
Follow these steps to file an appeal:
1. Gather all relevant information
The first step to appealing your insurer’s decision is to find out why your claim was denied. Get a copy of your denial letter and any document(s) submitted to your insurance as a part of the initial claim. This might include documents such as MRI findings, lab test results, operative reports, notes from your physician(s), letters of medical necessity, or medical bills related to the claim.
You should check your denial letter to find out when the deadline to file the appeal is. Your denial letter should explain when and how to file the appeal.
You will also want to get a copy of your insurance’s Evidence of Coverage document (sometimes called the benefit policy document). From this document you can determine what procedures your plan covers.
It can also be helpful to call the insurance company’s member services phone number. You can ask them for a detailed explanation of why the procedure was denied. If you can’t get a clear explanation that makes sense to you, you can ask to speak to a supervisor. Always ask the name of the people you speak with on the phone, write it down with the date you talk to them, and ask them to “put it in the record” that you’re working on disputing the claim.
2. File an appeal form or write an appeal letter
It is likely that your insurance company will have a standardized appeal form for you to fill out. If so, filling out their form will make the process move as quickly as possible. This form usually asks for most of the information you would include in an appeal letter.
If your insurance company does not have a standardized appeal form, you need to write an appeal letter asking your insurance company to reconsider their decision. Even if your insurance company has a standardized appeal form, an appeal letter can sometimes add more persuasive evidence.
This is known as an internal appeal. If the internal appeal is denied, you can appeal for a review by an independent third party. This is called an external appeal. The decision made by the external board is usually final and can’t be appealed.
The appeal letter should include the following:
- Your identification: your name, claim number, policy number, member ID number and any other information that will help identify you.
- Reason for denial: quote the exact reason for denial that they explained in the denial letter.
- Reason why you disagree with the denial: explain why you think the procedure should be covered. To make your case stronger, you can insert relevant language from your insurance policy document that indicates the procedure should be covered. You can also get a letter from your doctor explaining why the procedure is medically necessary and include medical document(s) that prove medical necessity.
- What you are requesting: Ask them to reconsider the denial and approve your claim based on the information you provided in the letter.
Click here for a sample appeal letter.
3. Contact your state’s Department of Insurance
If you need help filing an appeal, you can contact your state’s Department of Insurance for help. You can also contact them if you need to file a complaint against your insurance company. Click here to find your state’s Department of Insurance website.
Please contact the Breast Implant Information project for help filing an appeal at email@example.com.
All articles are reviewed and approved by Diana Zuckerman, PhD, and other senior staff.