How to Appeal a Denied Health insurance claim?

Health insurance denials have become increasingly common, causing significant revenue loss to practices. Denied claims are the claims that practitioners have submitted claims to the best of their abilities but are refused to be paid for by insurance.

Health insurance billing can be complex since patients are covered with different coverage plans. Figuring out what your patient has to self-pay and what insurance covers is critical before offering your services. However, even after following the guidelines and submitting legit claims, you are denied what’s due, you can fight back.

What do I do if my insurance claim is denied?

When your insurance refuses to pay for the claim, contact your payer and check why you were denied your claim. Ask them what you can do to reverse the decision. Be persistent. Constant follow-ups can sometimes help reverse the denial.

Appeal a denied insurance claim

Appeal a denied insurance claim

A denied claim does not mean that the insurance company will not ultimately pay the claim. If you think the basis on which the claim is denied is unsatisfactory, you can file a request for the insurance records for an appeal.

The law gives you the right to file a formal appeal with your health insurer. Every plan handles the appeals differently, hence you must first understand how appeals work for that particular plan.

There are two ways to appeal a denied health insurance:

  1. Internal Appeal – Via this appeal, the health care providers can ask the insurance company to conduct a full and fair review of the decision.
    • To file an internal review, insurance may ask you to fill out and submit a set of forms.
    • You may be asked to provide additional documents such as a letter to better back up the appeal.
    • o The appeal must be complete within the appeal limit. This may vary from payer to payer.

      After the evaluations, the insurance must provide you with a written decision. If the claim is still denied, you can ask for an external review.

  2. External Appeal – As a medical practitioner, the law gives you the right to appeal to an independent third party for review, and have the claim evaluated. With external review insurance no longer takes the final call whether or not to pay for the claim. The third-party decision is considered abiding and must be followed by the insurance.

If the health insurance company participates in a federal external review process, you must:

Submit a written request within four months of the claim denial using the portal’s secure website. Call on their toll-free number to request an external review form which you can submit by fax or priority mail. For a standard review, the decision is typically reached within 45 days of the request. Expedited reviews are decided as soon as possible, within 72 hours of filing the request. Here, the insurance company will not have the final say over whether to pay the claim.

You are entitled to ask your insurance company to reconsider its decision if you think the decision was not fair. Insurers must clarify on what basis they have denied your claim and you stand a chance of getting your claim processes if you have valid points.

If you have tried unsuccessfully to resolve the billing dispute or a denied claim, get in touch with a professional medical billing and coding company. Professional help can offer great offer assistance through the appeal process, and quick resolutions.


Leave your insurance eligibility verification to eClaimStatus. Get started with your 15-day free trial, call us at 310-294-9242 or write to us sales@eclaimstatus.com

eClaim Status

eClaimStatus provides simple, practical, efficient and cost effective real time Medical Insurance Eligibility Verification system and Claim Status solutions that power value added healthcare environments.