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How Do I Appeal a Medical Claim Denial?

Why Are Medical Claims Denied?

Medical claims can be denied for any number of reasons:

  • Your insurer does not have enough information to process your claim

  • You've reached your lifetime maximum limit with your insurance provider, so they can no longer pay for your claims

  • You've received services not covered under your plan

  • You've received experimental medical treatment

  • You have a pre-existing condition that prevents you from being covered for certain services

  • The provider put the wrong code for the service on your claim

You’ll need to know exactly why your claim was denied before you file your denial appeal letter.


What Makes a Strong Appeal?


You can help your chances of making a successful appeal by providing relevant information: this can be letters from your doctor, copies previous correspondence, and medical records. Also, it’s important to make sure you file your appeal through the proper channels; individual insurers may accept appeals differently based on the claim or plan--so be sure everything is going to the right place.


Other Considerations


It wouldn’t be a bad idea to contact your insurer beforehand to make sure you understand as much as you can about the denial and the appeals process. An appeal will be more likely to succeed if it’s tailored to the situation.


How Do I File the Appeal?


To appeal your claim, send an Insurance Claim Denial Information letter to provide additional information and request that your claim be reconsidered. If your insurer has their own methods or forms, be sure to use them.


What if the Appeal Is Denied?


If your insurance company continues to deny your claim and not cover your medical expenses, and you think they are wrong, you can contact your state insurance department or consider Asking a Lawyer.