How to Appeal a Denied Claim
Your health plan will review your coverage for a treatment, service, or prescription either before or after your claim is filed. If your health plan won’t pay for medically necessary services, treatments, or medicines, you have the right to appeal the decision through your plan’s internal appeal process.
Step 1: Review Your Plan
Check your health plan documents or contact your health plan or employer for details on your plan’s appeal process. A health plan will usually require you to fill out forms or write a letter to appeal the decision.
Step 2: Submit Your Appeal
You will usually have to file your appeal within 180 days (six months) of receiving notice that your claim was denied.
- You may send any other info that you want the health plan to consider.
- Your appeal does not need to be technical, but you should say what claim denial you are appealing and why you believe the company should review the denial.
Step 3: Keep Copies
Make sure you keep copies of all info about your claim and the plan’s denial, including info the plan gave you. This includes:
- Your Explanation of Benefits (EOB) forms
- Copies of any info you send to the company
- Notes from any conversation you have with your health plan about the appeal
Step 4: Requesting an Independent Review
When you have exhausted your health plan’s internal appeal process, you may have the right to have the decision reviewed by an outside independent review organization (IRO).
- Your health plan must give you an independent review form if it won’t pay your claim because it decided that the treatment is unnecessary, inappropriate, experimental, or investigational.
- Your health plan must pay for the review and must comply with the IRO’s decision.
- After you submit your appeal, the IRO must issue a decision within 5 days for emergency treatment and within 20 days for non-emergency treatment.
- Health plans do not have to provide an IRO for services it does not cover. Certain types of health plans such as Medicare, Medicaid, or ERISA plans do not have to participate in the IRO process.
- For more info on IROs, contact TDI’s Health and Workers’ Compensation Network Certification and Quality Assurance Office at 1-866-554-4926.
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