How to Appeal a Denied Health Insurance Claim

Did you recently get a letter from your insurer denying coverage for a test, drug, or other healthcare treatment?

If so, you’re hardly alone, whether you get insurance through your employer, buy it on your own, or are on Medicare. One recent study, for example, found that 17 percent of claims from people insured through an Affordable Care Act marketplace plan were denied in 2018. Another study, of people covered through a large Medicare Advantage insurer, found that nearly a third had at least one claim denied over a one-year period. Those denials can leave you on the hook for big medical bills..

But you don’t have to take it lying down, says Caitlin Donovan, a health policy expert at the Patient Advocate Foundation. She notes that there are steps you can take to fight those denials, regardless of where you get your health insurance. If you sought preauthorization for a healthcare service and were denied, you can appeal that decision, too.

First off, mistakes can happen at multiple points in the claim filing or preauthorization process, so phone your insurer to make sure the decision was not made in error. If it was not, ask to speak to the reviewer behind the decision and request an explanation. Keep notes, because you’ll need this information in writing later, Donovan says.