21 Jun Key Tips for Health Insurance Appeals
We’re sharing some key tips to help you receive the care you need if your health insurance company denies coverage for your medical care.
At some point during cancer treatment, you may experience a denial of coverage from an insurance company, whether for an imaging scan, prescription drug, treatment, procedure, or even a genetic test. Most people take “no” for an answer.
But, those who don’t accept the denial, and file an appeal, may actually win and get coverage for the care prescribed by their health care team up to 60% of the time! Visit TriageCancer.org/Cancer-Finances-Appeals for details on the steps to the appeals process based on the type of health insurance plan that you have.
Internal vs. External Appeals
If you have a private insurance plan, like a Marketplace plan, or a plan through your employer, you generally have two chances to appeal a denial of coverage: an internal appeal and an external appeal.
When an insurance company denies coverage for care, you can file an internal appeal, asking your insurance company to reconsider.
If your insurance company denies your internal appeal, you can request an external appeal, where an independent entity decides whether or not the care that you are being prescribed by your health care provider is medically necessary. If they decide that it is, then the insurance company has to cover your care.
Under the Affordable Care Act, all states must have an external appeals process – this is also sometimes referred to as External Medical Review or Independent Medical Review.
And don’t forget, you can file an appeal both before AND after medical services are provided. For more information on getting pre-authorizations before you receive care, visit TriageCancer.org/HealthInsurance.
Key Tips for Health Insurance Appeals
Step 1: Contact Your Insurance Company
- Contact the insurance company to ask for a detailed explanation of your denial and the company’s internal appeals process.
- Keep track of the dates of contact with insurance company representatives, names of individuals you talk to, notes of conversations, and any written documentation you receive. Our Health Insurance Appeals Tracking Form can help you stay organized.
- Ask family and friends to help you organize bills and insurance documents and take notes during calls with the insurance company.
Step 2: Understand Your Denial
There are several reasons why insurance companies may deny your claim, including:
- Mistakes: There may be errors with your patient information, billing details, or CPT/HCPCS codes. Review your bills, contact your provider and request they resubmit your claim with correct information, and explain the resubmission to your insurance company.
- Pre-Authorization: Insurance companies are not required to pay for care if you did not get a pre-authorization before you get care. Make sure to talk with your health care team to see if they are getting pre-authorizations from the insurance company. If they aren’t, then it is your responsibility to check to see if you need a pre-authorization from your insurance company.
- “Experimental or Investigational:” Your insurance company may deny your care, claiming that it is experimental or investigational. You can appeal these denials. Make sure to ask your health care team to help provide information about why your care is medically necessary.
- Service Not Covered: If your insurance company says your service is not covered, check your policy to see if the service is listed as “excluded.” If not, contact your insurance company and ask for more information about the denial. They may claim the service was unnecessary. If so, call your provider and ask for help showing that the care is medically necessary.
- Timely Submission: Claims submitted too long after services were provided may be denied. However, if your provider is within network, fixing this error usually only requires a phone call to your provider. As they are in charge of submitting claims, providers are usually held responsible for this mistake.
- Coordination of Benefits (COB): If you have both a primary and a secondary insurance policy, it’s essential to complete and submit COB forms every year. Failing to complete these forms can result in claim denials.
For a detailed explanation of the health insurance appeals process, see our Quick Guide to Health Insurance Appeals. Health care professionals can order free bulk copies at TriageCancer.org/MaterialRequest. You can also visit our Health Insurance Appeals Module on CancerFinances.org.
About Triage Cancer
Triage Cancer is a national, nonprofit providing free education to people diagnosed with cancer, caregivers, and health care professionals on cancer-related legal and practical issues. Through events, materials, and resources, Triage Cancer is dedicated to helping people move beyond diagnosis.
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