Health Care Claim Denied Fact Sheet
Fred’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.
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.
* As of March 2016
District of Columbia
HHS Administered Process/Independent Review Organization Process
Northern Mariana 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