Health Care Claim Denied Fact Sheet

Learn everything you need to know with this helpful Health Care Claims fact sheet from our experienced lawyers.

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icon1Fred’s son, Jimmy, exhibited behavioral challenges from a young age. As a teenager, Jimmy exhibited less control. Jimmy’s treating psychiatrist concluded that intensive out-patient therapy wasn’t working and Jimmy needed in-patient treatment. Jimmy’s psychiatrist determined the best treatment facility was located in the Western US, far from Jimmy’s home in an Eastern state. Fred’s health care insurer, part of the Blue Cross Blue Shield, was non-committal about pre-approval. The psychiatric facility agreed to accept Jimmy as a patient, because most Blue Cross system members covered the costs of care which ran $18,000 per month. After 6 months of in-patient treatment, Jimmy was discharged as his condition had markedly improved. The health insurer refused to pay the claim. Fred now faced paying a health care bill in excess of $100,000.

Disputing a Health Care Claim Denial

Having your health insurance claim denied from your insurance company can cause a great deal of financial worry especially if you have accrued large medical bills. We understand the panic and stress our clients feel about escalating medical bills, but there is light at the end of the medical debt tunnel.

The bad news is that having your health insurance claim denied is not uncommon for certain treatments. The good news is that when a claim is denied you have the right to demand that an insurer reconsider your health claim denial.

Remember a denial is the beginning not the end. If your plan reviews the case and still won’t reconsider its decision you have the right to appeal.

Don’t assume the process will be easy. Unfortunately, appealing a health care claim denial takes time and energy which is even more challenging when you or a family member is sick.

3 Common Reasons for Health Care Claim Denials


1. Improper coding of the procedure, or other errors on the part of the health provider.

2. Care that was performed outside of the health plan’s network.

3. Care that the insurer deems was not medically necessary, or was experimental.

Insurance Companies Have to Explain Why


After you or your medical provider have submitted a claim, by law health insurers have a limited time to explain in writing their decision to deny payment. Typically, the health insurer must provide

  • Timeline for Written Explanation of Denial of Payment
  • Within 15 days if you are seeking authorization ahead of treatment
  • Within 30 days for medical services you’ve already received

If the health insurance company says it won’t pay, you need to formally ask it to take another look at your claim. You must request this “internal appeal” within time limits of your plan. The time limits vary. Some are generous and can be as-long-as 1 year. Often the time limit is 60-days. Check your plan.

Quick Response to Appeals is Required


After your insurance company receives your request for an internal appeal, it must take another look at your claim and make a new decision. For urgent medical matters, this can be 72 hours or up to 60 days for other types of care.

Still “No” – Request an External Review *


If your claim is still rejected after your internal appeal, you can file for an “external review,” in which an independent third party will go over your case. Many states have external review procedures but not all. If your state doesn’t have an external review process that meets the minimum consumer protection standards, the federal government’s Department of Health and Human Services (HHS) will oversee an external review process for health insurance companies in your state.

Meets Parallel

Arkansas
California
Colorado
Connecticut
Hawaii
Idaho
Illinois
Iowa
Indiana
Kansas
Kentucky
Louisiana
Maine
Maryland
Minnesota
Mississippi
Missouri
Montana
Nebraska

Nevada
New Hampshire
New Jersey
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Rhode Island
South Carolina
South Dakota
Tennessee
Utah
Vermont
Virginia
Washington
West Virginia

Territory

Puerto Rico

* As of March 2016

Meets Similar

Arizona
Delaware
District of Columbia
Massachusetts
Michigan
New Mexico
Texas
Wyoming

HHS Administered Process/Independent Review Organization Process

Alabama
Alaska
Florida
Georgia
Pennsylvania
Wisconsin

Territories

American Samoa
Guam
Northern Mariana Islands
Virgin Islands

Usually the outside reviewers are health professionals who have experience managing medical issues in the nature of coverage sought. The quality varies by state. External reviewers consider

  • Any denial that involves medical judgment where you or your provider may disagree with the health insurance plan
  • Any denial that involves a determination that a treatment is experimental or investigational
  • Cancellation of coverage based on your insurer’s claim that you gave false or incomplete information when you applied for coverage

Good Chance of Winning Your Appeal


Many people give up too easily. Although a tedious process, we have found that if done correctly there is a good chance that you could win your appeal.