What Can Be Done If Claims Are Rejected or Denied Due to Errors?
Unsure why your claim was denied? This guide provides a structured approach to identifying errors, preparing your case, and pursuing a fair resolution.
When a claim is rejected or denied, it can be a frustrating experience. These denials are not always final, as they frequently stem from administrative oversights, missing information, or other correctable errors. Understanding that a denial is often a procedural hurdle rather than an absolute refusal is the first step in addressing the situation. This guide provides a structured approach to resolving such denials.
Understanding the Rejection and Gathering Information
The initial step after a claim denial is to fully understand the stated reasons for the rejection. Denials can occur for various reasons, including administrative mistakes like incorrect patient information, duplicate claims, improper coding, or a lack of documentation for medical necessity. Obtain and review the official denial letter, Explanation of Benefits (EOB), or similar documentation from the denying entity. An EOB is a statement from your insurance company detailing how a claim was processed, showing what was paid and what remains outstanding, but it is not a bill.
Within this documentation, identify specific denial codes, the reasons cited for the rejection, and any instructions regarding the appeal process. Understanding these codes is important, as they pinpoint the issue, such as a service not deemed medically necessary or an out-of-network provider. If the information in the denial letter or EOB is unclear, contact the claim processor for clarification. During this conversation, ask specific questions about the denial reason, noting the date, time, and the name of the representative you speak with, as this documentation will be valuable.
Based on the identified error, begin gathering all necessary supporting documentation. This may include policy documents, medical records from healthcare providers, invoices, receipts, and any prior communication logs related to the claim. For medical claims, you have a legal right under HIPAA to access your medical records from healthcare providers and health plans, which can be important for proving medical necessity. Providers may charge a reasonable, cost-based fee for copies. Organizing this information systematically will ensure easy access and reference throughout the subsequent steps.
Initiating the Appeal Process
With an understanding of the denial and all supporting documents gathered, the next phase involves initiating the appeal process. This begins with an “internal appeal,” the first step to request that the denying entity reconsider its decision. This internal review allows the company to re-evaluate the claim based on new information or supporting evidence.
Methods for submitting an appeal include online portals, mail, or fax, and the denial letter provides instructions on how to access appeal forms or where to send a written appeal. Your appeal submission should include a statement disagreeing with the denial, an explanation of the error, and all relevant supporting documents. For example, if a medical claim was denied for lack of medical necessity, a detailed letter from your doctor explaining the necessity, along with relevant medical records, would be important.
Adhering to specified appeal deadlines is important, as missing these can result in a denial of your appeal. Many health insurance plans require internal appeals to be filed within 180 days (six months) of receiving the denial notice. Maintain meticulous records of your appeal submission, including proof of mailing, copies of all documents sent, and the dates of submission. After submitting the appeal, you can expect an acknowledgment of receipt, and the entity is required to provide a decision within a specific timeframe.
External Review and Further Recourse
If an internal appeal does not result in a favorable outcome, individuals have the option to pursue an “external review.” This process involves an independent third party, not affiliated with the denying entity, reviewing the claim and the appeal decision. For health insurance claims, this independent review is conducted by an independent medical professional or an Independent Review Organization to determine if the treatment was medically necessary.
To initiate an external review, contact the appropriate regulatory body in your state, such as the state Department of Insurance or a consumer protection agency. These agencies often have forms and procedures for requesting an external review, and you will need to provide the final denial letter from your internal appeal, along with all supporting documentation previously gathered. Federal standards and many state laws require insurers to accept the decision of the external reviewer. The timeframe for filing an external review is typically within four to six months after receiving the final adverse determination from your internal appeal. Decisions are usually rendered within 45 days for standard reviews or as quickly as 72 hours for urgent cases where health is at serious risk.
Beyond external review, various other avenues of recourse exist. State consumer protection agencies and ombudsmen offices can offer assistance and investigate disputes, working to ensure fair treatment from companies. These governmental bodies can often provide guidance and intervene on your behalf. For complex or high-value claims, seeking professional assistance from an attorney specializing in consumer law or a professional patient/claim advocate can be beneficial. These professionals can review policy documents, negotiate with the denying entity, and represent your interests, helping navigate intricate legal and procedural aspects. Throughout these escalated processes, maintaining thorough records of all communications, submissions, and decisions remains important to support your case.