Dealing with uncovered medical expenses can be a very stressful experience that causes high levels of anxiety, especially for students and international travelers located far from home. For this reason, it’s important that you understand which are the options available to you if you disagree with your insurer’s decision to deny your claim.

Appealing a denied health insurance claim can be a challenging process, but knowing the steps to take and your rights can make a big difference. If your insurer has denied coverage for a medical treatment or procedure, you’re not alone. Follow this guide to understand how to submit an effective appeal and improve your chances of success.

1. Understand the Reason for the Denial

Before planning your appeal, the first step is to carefully review the denial letter from your insurer. This should clearly state the specific reason for the denial. Common reasons include:

• Treatment considered elective and not medically necessary.
• The treatment received for an injury or illness was not covered by the policy, meaning it falls under the policy’s general exclusions. Common exclusions that can lead to a denied claim include pre-existing conditions or medical expenses associated with routine or preventive care.
• Insufficient or contradictory information included in the medical records.

Once you have identified the reason for the claim denial, it is very important to review the terms and conditions of your policy, especially the coverages and exclusions. Your insurance coverage certificate will be accessible to you immediately after completing the purchase of your insurance.

If the medical expense incurred is listed as an exclusion in your policy, it is unlikely your insurer will reconsider the claim, even if you file an appeal. However, using an example, if the claim denial was due to an alleged pre-existing condition and you have evidence to prove that this determination was incorrect, then it’s recommended to appeal. Keep reading to learn more about what documentation you’ll need to prepare your appeal.

2. Gather Relevant Documentation

For an effective appeal, gather all the necessary information and documentation to support your case. This could include:

• The insurer’s original denial letter so they can identify the claim you wish to appeal.
• Medical records. For example, if the reason for denial was that the illness was pre-existing, the medical records you attach should prove that the condition in question was not pre-existing.
• Letters from your doctors.
• Summaries of benefits and the insurance policy describing the coverage.

This documentation is essential to support your case and demonstrate that the requested treatment is necessary.

3. Understand the Timeframes and Types of Appeals

In the U.S., insurers generally offer two types of appeals:

• Internal appeal: Conducted within the same insurance company, and this is the first step in the process.
• External review: If the internal appeal is denied, you can request an independent entity to review your case. This is mandatory in most states and managed by an impartial third party.

The timeframes for filing an appeal vary depending on the insurer. Some insurers give you a period of 90 days after the denial, while others allow up to 180 days to file your appeal. It is very important to review your policy to ensure you meet specific deadlines, as if the insurer receives your appeal outside the stipulated timeframe, it will not be processed.

The timeframes for filing an appeal vary depending on the insurer. Some insurers give you a period of 90 days after the denial, while others allow up to 180 days to file your appeal. It is very important to review your policy to ensure you meet specific deadlines, as if the insurer receives your appeal outside the stipulated timeframe, it will not be processed.

4. Write Your Appeal Letter

Writing a clear and concise appeal letter is key to presenting your case. Here are some tips:

• Start with a summary that includes your policy information, the denial date, and a brief description of why you’re appealing.
• Explain the treatment and its importance, supported by statements from your doctors.
• Argue how the treatment meets your policy terms and refute the reason for the denial (for example, if they consider it unnecessary, explain why it is).
• Attach all supporting documents.

A well-structured letter can demonstrate that the treatment meets policy criteria and medical necessity.

5. Regularly Follow Up on Your Appeal

The appeals process can be slow. Insurers generally request up to 90 days to review the appeal and provide a new determination.

It is important to stay in contact with the insurer, confirm that they have received all your documents, and regularly check the status of your appeal. Keeping a detailed record of all calls, representative names, and dates can be very helpful to have a complete history of your case.

My Appeals Were Denied, Now What?

While there are many cases where appeals are successful, unfortunately, the reprocessing of claims does not always result in payment. Although this can be discouraging, there are still other options for dealing with uncovered medical expenses.

Hospitals have financial assistance departments where you can explain your situation. In some cases, the medical provider may reduce the debt or offer a payment plan with affordable monthly installments to help you pay off the debt. To review different ways to deal with uncovered medical expenses, we recommend checking out our blog “How to deal with medical debt in the US”.

Appealing a health insurance claim in the U.S. can be a complex and time-consuming process, so it’s important to understand the steps to follow to prepare the documentation and arguments you’ll use during your appeal to increase the chances of the best resolution. It is essential to know and understand your policy’s coverages and exclusions, as well as the deadlines set by your insurer to submit your appeal so that it can be processed in a timely manner.