How to appeal a health insurance denial
You can win an appeal, but it takes some work. First, read the denial letter. Why was coverage denied? What's the appeals process and timeline?
If it's a billing or claims-processing error, call your medical provider's billing office and ask them to clear things up with the insurer. If a bill is due during your appeal process, consider these suggestions.
If it isn't a billing or claims-processing error, you'll need to appeal to overturn it. Here are some suggestions that might help.
For continued care in an urgent situation
A health plan must provide continued coverage pending the outcome of an appeal. It can't reduce or stop benefits for an ongoing course of treatment without providing you advance notice and an opportunity for review (RCW 48.43.535(7) (leg.wa.gov).
Note: if you lose the appeal, you may be responsible for those medical costs.
Tips for filing your appeal
- Find out the deadline for an appeal. Where do you send it? These are usually in the denial letter. If not, ask your insurer.
- Determine if you have a non-grandfathered plan or a grandfathered plan and what your appeal options are for your particular plan. If you're not sure which kind of plan you have, call your carrier and ask them.
- Keep a log of every call, email and letter. Here's a printable example (PDF, 647KB) of a contact log.
- Gather your medical records. If you don't have them, ask your medical provider for copies. Here's an example letter. (Word, 32KB)
- Appeal letters should be to the point, timely and specific about the outcome you seek. Here's an example appeal letter (Word, 24KB) and a list of common reasons for a denial and example appeal letters you can use.
- Look at other independent review organization (IRO) decisions for health insurance appeals using our searchable IRO database.
- It helps to have a supporting letter from your medical provider. Give them a copy of the reason for denial.
- Don't be afraid to call, especially if someone said they would get back to you and they didn't.
- Send copies of documents, not originals, and send them as certified mail.
You may want to also file a complaint
Whether or not you file an appeal, you may also want to file a complaint with our office. The appeals and complaint processes are different, and can take place simultaneously without affecting each other. If in doubt, you may want to try both avenues to resolve your issue.