What to do when a claim is denied

A denial is the beginning of a process, not the end of one. Marketplace plans carry appeal rights that include review by someone outside the insurer, and denials are overturned more often than people expect — largely because the first refusal is frequently a paperwork outcome rather than a clinical one.

The deadlines are the unforgiving part. Everything else is manageable.

First: read what actually arrived

You will receive an explanation of benefits or a denial notice. It is not a bill, and it says three things you need:

• what was denied;
• the reason, in a code and usually in a sentence;
• how to appeal and by when.

Note the date on the notice. Every deadline that follows is counted from it, and losing track of that date is the commonest way a good appeal never happens.

Check the boring explanations first

A large share of denials are administrative, and a telephone call fixes them:

• a coding error at the provider’s office;
• the claim submitted to the wrong plan, or before coverage started;
• a prior authorisation that existed but was not attached;
• a provider listed as out-of-network who is not, or the reverse.

Telephone the provider’s billing office and the plan, in that order, with the notice in front of you. Ask each what they think happened. If they disagree, you have found the problem.

The two levels of appeal

Internal appeal. You ask the plan to reconsider. This is where your prescriber’s or physician’s supporting statement carries the most weight.

External review. If the internal appeal fails, you can ask for review by an independent organisation with no relationship to the plan. Its decision binds the insurer. This is the part people most often do not know they have.

There is also an expedited route for both, where waiting would seriously jeopardise your health. Your clinician can request it, and if they support it the plan must use the shorter timescale. Use it when it is warranted, not routinely.

What actually persuades

Appeals succeed on clinical specificity rather than on indignation.

Get the clinician involved on day one. Telephone the practice and ask for whoever handles appeals and prior authorisations — every practice has one, and it is rarely the doctor.

Say what was tried and what happened. “Tried the preferred alternative in March, discontinued after two weeks because of X” does more than a page of argument.

Name the contraindication. If the plan’s preferred option is unsuitable because of another condition or medication, state it plainly.

Attach the evidence. Notes, results, prior correspondence, the denial notice itself.

Keep it to the point. The reviewer is deciding one question.

Practical mechanics

Put everything in writing even when you also telephone. Note the date, the time and the name of everyone you speak to. Keep a copy of everything you send, and send anything important by a method that proves delivery.

If someone is helping you, the plan will need an authorised representative form before it will discuss the case with them. Complete it early rather than at the deadline.

Where to complain if the plan is the problem

Beyond the appeal itself, you can complain to your state’s department of insurance — Kansas, Missouri, Nebraska and Iowa each have one, and each handles market conduct in its own state.

The Marketplace Call Center on 1-800-318-2596 (TTY 1-855-889-4325) can also help with coverage questions and will point you at the right route.

What we do, and what we do not

We are insurance agents, not lawyers or medical advocates. We do not decide appeals and we cannot make a plan pay a claim.

What we will do, if we placed your plan: read the notice with you, tell you plainly whether it looks like an administrative error or a clinical refusal, find the right number, and make sure you know the deadline. There is no charge and it takes about twenty minutes.

Navigators and certified application counselors help with this too, free, and are not paid by insurance companies — localhelp.healthcare.gov.

The one thing not to do is nothing. The deadline is the only part of this that cannot be recovered.