UNDERSTANDING THE APPEALS PROCESS

An appeal is a request to your insurance company for review of a denied claim or service.

A denial by your insurance company indicates that it has decided not to pay for the claim or service recommended by your physician. Even if you follow prior authorization and claims submission processes accurately, your insurance company may still deny your request for coverage.

Denial of Claim Explanation

If you have received services and the claim is denied, you and/or your medical provider should receive an Explanation of Benefits (EOB). If a portion of the claim was denied, there will be an explanation detailing the reason for the denial.

If prior authorization is denied, you and/or your medical provider should receive a letter stating the reason for denial. Carefully review these statements and use them to assist with submission of an appeal.

There are many reasons why claims are denied. Here are some of the common reasons claims are denied.

If you have been denied service, the next step will be to file an appeal. Learn about how to submit an appeal.