After undergoing a procedure for your cancer treatment, your health insurance provider sent you a “health insurance claim denied” notification, also known as a determination letter. You received this notice despite making sure your health insurance coverage was in order beforehand. What gives?
When a claim for benefits is denied, you will ultimately be responsible for the entire cost. Getting a claim denial overturned isn’t impossible, but it will require phone calls, paperwork and patience.
Here’s how to make any appeal process go a little bit smoother:
Rule Out Coding Errors
A phone call to your health care provider can determine if a simple coding error tripped the denial and, if so, a corrected claim can be submitted.
Get Professional Help
To expedite the process, work with a financial counselor at your cancer treatment center. They can serve as the go-between with your cancer care team, your hospital’s billing department and your insurance provider. Otherwise, you’ll need to let billing know you’ve filed an appeal so your account isn’t sent to a collection agency.
For additional help, the nonprofit Patient Advocate Foundation (PAF) provides free access-to-care services for patients with chronic, life-threatening or debilitating diseases. You can get appeal assistance from a PAF counselor.
File the Correct Appeal
According to the Centers for Medicare and Medicaid Services, the Affordable Care Act created national standards for filing both internal and external appeals. You, your health care provider or an authorized representative can file internal appeals with your insurance company. The Consumer Assistance Program in your state can also file your appeal.
Your insurance determination letter should explain why your claim is being denied and provide detailed information on each of the appeal processes available to you. If you don’t receive a determination letter, call your insurance provider to request it and any documentation they used to come to their determination.
If a claim is deemed “not medically necessary” or “experimental” — two of the top reasons for claim denial according to the Virginia Bureau of Insurance — ask your doctor to provide a written explanation of their reason behind the treatment plan.
For any treatment requiring immediate action, you or your doctor can request an expedited or urgent appeal, where the health insurance provider must respond within 72 hours.
After internal appeals fail, you have the right to an external appeal, in which a third party decides whether the insurance company should pay the claim. Every state has its own department of insurance which oversees the external appeal process. The National Association of Insurance Commissioners maintains an online searchable map. Once both internal and external appeals have been exhausted, you can file a complaint with your state department of insurance.
Keep Good Records
File all appeals in writing, so there’s a clear paper trail. Keep copies of all documents submitted on your behalf. For any phone conversations, keep detailed notes of what was said, the time and day you called and the name of the insurance and billing department representatives.
File on Time
Each appeal process has a time limit to file, and a time limit by which the insurer must respond. Tackle claim denials in a timely manner so you’re able to use all your options.
Avoid Future Claim Denials
Before any treatment, confirm your doctor obtained necessary insurance predeterminations. Unlike pre-authorizations (which aren’t a guarantee of payment), with predeterminations your insurance provider has already determined the requested service is medically necessary and falls under the plan’s coverage guidelines.
With enough organization, persistence and diligence, receiving “health insurance claim denied” notifications will be a thing of the past.
You don't have to go through the appeal process alone. UVA Cancer Center's financial counselors can help.Learn More