5 Tips for a Successful Medical Claim Appeal

Health Insurance Denied Form Showing Unsuccessful Medical ClaimIt can feel like you’ve been thrown a real curve ball when your medical claim is denied, and like you’re about to climb a major mountain.  The good news is that the “climb” is usually worth it; the majority of medical claim appeals are resolved, making appealing your claim a worthwhile effort.

Understand your Explanation of Benefits.

For every appointment or service you receive, you should receive an Explanation of Benefits (EOB).  Your EOB should include the date of service,  service(s) provided, how much your insurance covers, how much you owe, any reasons for denial (if applicable), and any other pertinent information.  If your claim was denied, the EOB should list the reason for denial usually with a code.  If you don’t understand the reason, contact your insurance company for an explanation.

Start with a phone call.

There may be an easy resolution to your claim denial.  Start by calling your medical insurance company.  Ask about the reason for the denial, the process to resolve the issues and a possible appeal (not all denials require an appeal for a successful resolution).  Sometimes a medical claim denial can occur because of an error in coding, incorrect patient information (i.e. wrong insurance ID number, etc.), or simply sending the claim to the wrong company.  An example of this would be if your eye appointment was sent to your health insurance in lieu of your vision insurance.

Stay calm.

Take a deep breath before you call insurance and doctor’s office.  The representative on the phone is not the enemy, BUT don’t be afraid to ask for a supervisor that can give you more information.  Be calm.  Prepare a list of questions you need answered so you can get all the information you need during the phone call.  Be prepared to call your doctor’s office next for supporting documentation.

Develop a system.

Now is the time to keep careful notes and be organized.  Note all representatives you talk to, date and time of the call, paperwork needed, deadlines, and dates when paperwork was sent in (either by you or the doctor’s office).  Keep a file with all relevant documents and records.  When you do have to submit documentation, double check your letters and documents to make sure that all required information is included.  Don’t be afraid to go above and beyond the minimum requirements to ensure a smooth appeal process.

Don’t be afraid to ask for help.

There are numerous resources that can help you as you navigate through the appeal process.  Some companies even offer advocacy services to assist.  Find out if your company is one of them.  For a major claim denial, consult with an attorney experienced in claim denial.  An attorney can assist you in navigating through the system and increase your chance of a successful appeal.

The materials on this website are provided for informational purposes only and do not constitute legal advice. These materials are intended, but not promised or guaranteed to be current, complete, or up-to-date and should in no way be taken as an indication of future results. Transmission of the information is not intended to create, and the receipt does not constitute, an attorney-client relationship between sender and receiver. You should not act or rely on any information contained in this website without first seeking the advice of an attorney.