How to File an Appeal for a Medical Claim Denial

The first step in appealing a medical claim rejection is to carefully study your insurance provider’s explanations of benefits (also known as an EOB). The EOB is the first place to examine to see how much of the claim was covered by insurance and paid to the health care provider. It is also where you will learn whether or not your medical claim was denied.

Medical claims may be dismissed for a variety of reasons, including:

Your insurer lacks sufficient information to process your claim.
You have hit your insurance provider’s lifetime maximum limit, and they can no longer pay for your claims.
You obtained services that were not covered by your plan.
You had experimental medical therapy.
You have a pre-existing condition that precludes you from receiving some treatments.
Your claim was coded incorrectly by the supplier.

After you have determined the insurance company’s reasons for denying your claim, do your homework to make the strongest possible appeal. This includes speaking with your doctor to better understand your sickness or injury, obtaining copies of communications between your doctor and insurance provider, reviewing your insurance policy’s coverage, and learning how to appeal a claim rejection under your particular plan. (Depending on the nature of issue, there may be multiple appeals procedures). Contact your insurance carrier to learn more about your claim rejection so you may address their concerns in your resubmitted claim. Sometimes all that is required is more information regarding the services you got before your resubmitted claim is approved.

Send an Insurance Claim Denial Information letter to give more information and request that your claim be evaluated to appeal your claim.