Smart Ways to Fight Denied Claims

Appealing a denied claim? Make your voice heard with this expert strategy.

by Meryl Davids Landau
Photograph: Kirby Hamilton

Here’s the good news: “Many claims that are initially rejected are paid after the first appeal,” says the Access Project’s Mark Rukavina. Follow these steps to win this critical battle:

> Ask for a written copy of the denial That way you’ll be able to address your insurer’s objections point by point in your letter of appeal.

> Watch the clock You have only a certain amount of time to appeal the denial; the cutoff date is indicated in your denial letter. No matter what, do not miss the deadline.

> Enlist some help Contact HR to see if your policy covers the disputed treatment; if it does, a complaint from the department to the insurer typically carries additional weight. Ask your doctor to write her own appeal letter (to be attached to yours); for maximum effect, tell her why your claim was rejected, so she can better justify her recommendation, suggests Erin Moaratty of the Patient Advocate Association.

> Craft your appeal with care Your mission: to convey, in a factual, unemotional tone, the reasons thetreatment is truly “necessary.” It’s crucial that you state every conceivable reason, because if you later go to court, you won’t be able to add to the arguments raised in this appeal. (Sample letters are at patientadvocate.org.) Besides your letter, your packet should include your doctor’s letter, relevant medical records and any other documents that support your case.

> Consider further action If your appeal is rejected, you can submit a reconsideration to the insurance company. Or you can request an external review. Mandated in most states (find your insurance commissioner at naic.org) and standard policy at some insurers, an external review will bring in an outside company or a state review board to take an unbiased look. (This third party cannot, however, override limits in your policy.) If that fails and the cost of the procedure you need or have already paid for is substantial enough, you may decide it’s worth hiring a specialized lawyer to take the insurance company to court.

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