Posts Tagged: appeals

Why Did my Health Insurance Deny My Claim!?

No! You expected your health insurance to cover a service, and then you get the dreaded letter that it’s been denied. Why do claims get denied and when does it actually matter (that’s right, sometimes it doesn’t matter)?

Your health plan might refuse to pay for a service or treatment you received for many reasons. It’s good to know whether it was denied because of the services themselves OR because of how your provider submitted it. Why is this important? Because in the first case, you’ll probably be responsible for paying the claim. In the second, you won’t be.

Here are some common reasons claims get denied where you could be responsible:

  • You didn’t get a referral or prior authorization when it was required
  • The service isn’t covered by your plan
  • You already used up your benefits for the service (like a cap on the number of physical therapy visits per year)
  • You went out of network when you have an HMO
  • Your insurance wasn’t effective at the time of the service

Don’t confuse these situations with those where a claim (or a portion of a claim) was denied because of how your provider submitted it to your insurance. This happens surprisingly frequently.  It might be that:

  • Your doctor didn’t submit the right billing code to your insurance plan
  • Your doctor didn’t submit the claim in the timeframe your insurance required
  • The service was actually covered as part of another claim or set of services
  • The claim is a duplicate that was already paid

You might see these things show up on your EoBs, or Explanation of Benefits–the statements you get from your health plan just informing you about your coverage (the ones that say “This is Not a Bill”). Just know that if your provider made a mistake submitting a claim, or your insurer found that it had already been paid for, you’re not responsible!

So before you panic, look into the reason for the denial. And if you believe you were billed unfairly for the cost, you can always appeal the decision. All health plans have to honor a process of reviewing claim appeals from their members.


How To Appeal a Denied Health Insurance Claim

Anyone who has ever submitted more than a very basic claim to their health insurance company has probably dealt with having a claim denied.  It can be a very frustrating experience, and sometimes it feels like the insurance company is trying to wear you down until you just give up.  But the Affordable Care Act, aka “Obamacare,” has several provisions that can help by regulating how insurance companies must deal with appeals.

Let’s say you received a bill for your MRI when you know your plan covers them. Or your plan requires prior approval before a hospital stay but they deny your doctor’s request even though you believe it is medically necessary.  Whereas in the past your appeal would be handled differently depending on your plan’s rules, there is now a standardized appeals process that plans must follow.

If you joined your health plan after March 23, 2010, these rights apply to you. For plans created on or before March 23, 2010 (known as “grandfathered plans”), you may not have the same rights. 

Here’s what happens:

If your plan decided not to cover or authorize a service, you have the right to request an internal appeal: the plan must review their decision and provide you with a response within

  • 72  hours for urgent care claims
  • 30 days for non-urgent care claims
  • 60 days for services you have not yet received

Starting January 1, 2012, if your plan denies your appeal, you can request an independent external review. If this decision is made in your favor, the plan must cover the services. Some states have already created a process for external reviews, so you may not have to wait until 2012.

Also, some plans may have additional levels of internal review before you can ask for an external review, though the entire process must occur within the timelines above. Check with your state’s Department of Insurance or with the plan for specific rules.

Is an appeal worth your time? 

It just might be. A study by the Government Accounting Office found that anywhere from 39% to 59% of internal health plan appeals filed are ruled in the patient’s favor. And about 40% of external reviews go in the patient’s favor (

For help with appeals, some states offer Consumer Assistance Programs. Look for yours at

Simplee will notify you when you have claims that have been denied, and also provides you information you can use to contact your insurer to begin the appeals process.  To look at the details of individual claims, click on them in the “Clams & Bills” tab to see the detail.  Insurer and provider contact information is in the right sidebar.