Picture this: You go to the doctor for the flu, to urgent care for a sprained wrist, or to the hospital for surgery. Once you’re home recovering, you receive notification your health insurance is denying coverage of the related charges. Now what?
Hit the pause button on the stress attack you feel coming on and turn that energy toward writing an insurance appeal.
Under the Affordable Care Act (ACA), everyone has the right to appeal when coverage is denied. An appeal is a request to review the denial decision. You can appeal a health plan decision either internally (directly to the health plan itself) or externally (by going through an outside organization). If you decide to start with an internal appeal, you have 180 days from the time of the denial and the request must be in writing.
Here’s how to write a compelling appeal letter.
What to include in your appeal
To make it easy for your health insurance company to understand the issue, include these details at the beginning of the letter:
Your name (as it is listed on the policy, including middle names/initials used on the policy)
Policy number (found on your insurance card)
Policy holder’s name
Your contact information (mailing address and phone number)
Date of denial, what was denied, and the cited reason for the denial (this chunk of information can be found on the Explanation of Benefits paperwork you received with the denial)
The healthcare provider’s name and contact information
State the reason for your appeal
Dive into the specifics of why you believe your insurance policy covers the treatment or service that has been denied. Mention the specific language in your policy that leads you to believe an error has been made.
For example, your doctor may have removed a mole that they suspected might be cancerous, but the service was improperly coded as “cosmetic.” If your plan doesn’t cover cosmetic procedures, coverage for the service could be denied. Your letter should explain the mistake you believe has been made.
You should also request a statement from your healthcare provider explaining why you required the treatment or service. This statement should be included when you send your appeal letter. The letter from your healthcare provider should also explain any errors that they made (if applicable). The previous example of improper coding would be considered an error made by the healthcare provider.
Refer to any pre-authorizations (if submitted), previous claims that have been approved for the same treatments, X-rays or other medical records that back up your case, etc.
Be concise, but don’t leave out any details related specifically to the denied service.
Send your appeal
Some insurance plans may allow appeal letters to be sent via fax, but most require delivery via snail mail. If you submit the letter by fax, keep the confirmation of successful transmission until the entire appeal process has been completed.
If using snail mail, send the letter via certified mail and request a return receipt (proof of delivery). You must keep a copy of all items that you send to the insurance company (your letter, providers’ statements, etc.), along with the proof of delivery. Store them in an organized way in a safe location so you can easily access them if needed. You should retain all this information until the entire appeal process has come to a close.
How long does it take for appeals to be reviewed?
Your insurance company should notify you within 10 days that your appeal has been received. If you do not receive confirmation (which will typically be in written form), contact your insurance company to make sure your appeal has been received and is logged in their system.
Your insurance company must make a determination on the appeal within 30 days and you should be notified of that decision in writing.
What should you do if your appeal is denied?
If your internal appeal is denied, you still have one more option you can pursue. The ACA allows you to request an independent external appeal, which is conducted by a third party instead of by the insurance company.
When an appeal is denied, the ACA requires health insurance companies to notify you of why your appeal was denied and of your right to an external appeal. You must also be notified of the availability of a Consumer Assistance Program (CAP), if your state has one. You can find more resources at HealthCare.gov.
The bottom line
If your insurance plan denies coverage of a treatment or service that you believe it is supposed to cover, you can write an appeal letter. This letter should include details about the denial and why you believe an error has been made. Before submitting an appeal, you should review all the rules related to appeals and understand your rights. This will help you to better advocate for yourself after your health plan denies you coverage. If the insurance company denies your appeal, you also have the option to ask an independent organization to review the claim.