Your insurance company might decide not to pay for a claim or service your physician recommended. Even if you submitted complete and comprehensive prior authorization and claims, your insurance company still might deny your request for coverage. However, insurance companies reverse many claim denials after an appeal.

If your insurance company denies a claim after you received services, you and your medical provider should receive an explanation of benefits, which includes reasons for the denial. If the insurance company denies part of the claim, the explanation of benefits will state the reason.

Similarly, you should receive an explanation letter after an insurance company denies a prior authorization request. Carefully review those statements and use them to help your appeal.

Does your insurance plan require prior approval before it will pay for treatment? Learn how health insurance companies control costs by limiting access to expensive care.

Prior authorization

Reasons for denials

Some common scenarios for service or claim denials include:

Services not covered by your health plan. Some insurance companies won’t cover specific services, health care providers or treatments. The practice is known as benefit exclusion. The most common exclusion you will face is that your insurance plan’s formulary doesn’t include your pulmonary hypertension drug.

Medical necessity wasn’t established. An insurance company can deny a prior authorization or claim if it doesn’t think a medication or treatment is appropriate for your diagnosis. Many health plans require you to try several treatment options before they cover more costly alternatives, a policy called step therapy.

Incorrectly filed claim. Many insurance claim denials result from filing or processing errors. Those reasons won’t appear on your explanation of benefits, so they won’t be as easy to spot. Work with your health care team and the insurance company to confirm that the services the insurance company thinks you received align with what was billed. Ask the insurance company to check the diagnosis code. A mistake in the code could also affect which services your plan covers.

Tip: Work with your provider to collect all previous medical history and chart notes to support the need for the denied medication or service. The documentation will be important in your appeal.

Submitting an appeal

No matter what type of insurance you have, you have the right to appeal a denial. Your health care team typically will file an appeal for you. If you need to appeal denied insurance coverage, follow these steps:

The process for appealing a denial varies among health plans. Call the customer service or claims department to help you follow your plan’s process correctly.

Ask for a copy of the denial if you don’t have one.

Inform your insurance company that you want to appeal its denial.

Ask about the appeal process, including these questions:

  • Why did it deny the prior authorization or claim?
  • Who must initiate the appeal (you or your provider)?
  • What is the appeal process?
  • How long will it take to get an answer once you submit an appeal?

In most cases, you must submit an appeal letter and documentation that supports why your insurance company should pay for the requested health care service. Your health care team often has experience writing these letters and knows how to make them successful. If you are writing the letter yourself, ask your health care provider to review it.

Make sure your appeal includes:

  • Your insurance information, such as your policy number and group number, so your account is easily identifiable.
  • A summary of the denial based on the denial letter you received and your discussion with the insurance company.
  • Your medical history related to your diagnosis. Your physician should give you relevant documentation from your medical records.
  • Medical treatments previously tried for your condition and the results.
  • Explanation of why your insurance company should reconsider its denial and approve coverage.

The insurance company might require a letter of medical necessity from your doctor. It might be helpful to include a letter even if it’s not required. Consider submitting drug label information, clinical trial results and published research about the value of the prescribed care for people with your condition. Those documents could help strengthen your appeal.

Follow your insurance plan’s directions for submitting an appeal and additional documentation. You likely can do this online. Mailing and faxing your appeal are other options.

Don’t forget to:

  • Copy the appeal and related documentation for your own records.
  • Call to confirm that your insurance company has received your appeal.
  • Call to check on the status of your appeal. When you should call or how frequently depends how long the insurance company told you it would take to review the appeal.

Get more insurance guidance