INDIANAPOLIS (WISH) — If your health insurance denies coverage for a test, treatment, or medication your doctor recommends, don’t rush to cover the cost yourself. You have the right to appeal, and it may be easier than you think.

According to Consumer Reports, nearly 1 in 5 in-network claims from plans sold on Healthcare.gov were denied in 2023. That number jumps to more than one-third for out-of-network care. But a denial isn’t necessarily the end of the road.

Step One: Double-Check for Errors

Start by calling your insurance provider. In many cases, a denial stems from something as simple as a billing mistake or a missing piece of paperwork. These kinds of issues are common and can usually be resolved quickly once identified.

Step Two: Ask Questions and File an Appeal

If the denial isn’t a mistake, you still have options. Ask to speak with the reviewer who made the decision. Get a clear explanation as to why your claim was denied, this will be key when you file a formal appeal.

Then, get your doctor involved. Ask them to write a letter explaining why the treatment is medically necessary. Back it up with documentation, including your medical records, relevant research, and any communication with your insurer. Most providers are familiar with this process and can help you build a strong case.

Step Three: Be Patient or Request an Expedited review

Once you’ve submitted your appeal, the waiting begins. A decision could take up to 30 days or more. If your situation is urgent, ask for an expedited review.

If your appeal is still denied, don’t give up. Whether you have Medicare or private insurance, the company is legally required to provide a written explanation, and tell you how to escalate the appeal to an independent third party.

Extra Help is Available

If you get insurance through your employer, consider reaching out to your HR department for help navigating the process. If Medicare is involved, you may want to seek legal assistance to make your case before an administrative law judge.

And if you receive a surprise medical bill despite laws that are supposed to protect you from them, Consumer Reports suggests asking for an itemized bill and questioning every charge before making any payment.

Bottom line: A denied claim isn’t always final, and you don’t have to face it alone.

For more information, click here.

About The Author

See author's posts