When you receive medical care, either you or your provider (doctor, hospital, therapist, etc.) must file a claim with your health insurer. Often, the provider files the claim.
Most of the time, the insurer pays the claim. But, sometimes the insurer refuses to pay part or all of the claim for services you believe should have been covered. You have a right to appeal that decision.
There are two types of appeals—an internal appeal and an external review.
Here are the steps you can take if your insurer denies a claim
File an Internal Appeal
You file an internal appeal to ask your insurer to review a decision to deny a claim. You have up to six months (180 days) after you learn a claim was denied to file an internal appeal.
- To learn how to file an internal appeal, look at the claim denial or call the customer service number on your insurance card/ materials. You can also find the process to file an internal appeal at the MIA’s website at: https://bit.ly/miaccp.
- An internal appeal usually requires you to write a letter. Be sure to include in the letter your name, claim number, and health insurance ID number, and any other information you have to support your claim. (See reverse side for sample letter.) If the insurer denied a claim for a medical reason, you’ll need your health care provider’s help to file an appeal. Ask your provider to write a letter explaining why the care was medically necessary. Send that letter with your appeal.
After it receives your appeal, the insurer has a set amount of time to review it and make a decision. If the denial was because the insurer says the care is not medically necessary, the insurer has 30 working days to make a decision if care has not been provided yet, and 45 working days to make a decision if the care has been provided. If the insurer denied the claim for other reasons, the insurer has 60 working days to issue a decision. If a delay in receiving medical care could harm your life, health, or ability to function, you can ask that the appeal be reviewed quickly (“on an expedited basis”).
And if your insurer still says “No”….
File an External Review
If your insurer still denies the claim after the internal appeal, you can ask for an external review. An independent review organization will do the external review. You may have a limited time to ask for an external review after you receive the decision from your internal appeal.
- You should find the information about how to ask for an external review on your internal appeal notice.
- The Maryland Insurance Administration is in charge of the external review process for many health plans issued in Maryland. You may be able to start the process by sending a complaint.
- You can submit information you didn’t include in your internal appeal to support your position.
- The external reviewer has a limited time to reach a decision.
- The external reviewer will give you and your insurer a written notice of its decision.
- The insurer must pay the claim if the external reviewer decides the insurer should.
Things to Keep in Mind
Medicare and Medicaid
If you’re enrolled in Medicare or Medicaid, there are different rules for appeals.
- For Medicare, call 1-800-MEDICARE to ask for information about free help to appeal a decision.
- For Medicaid, contact HealthChoice, Maryland’s Medicaid Managed Care Program, at 1-800-284-4510 for help.
Keep Records
Keep detailed records, including bills from your provider, notices from your insurer, copies of denial letters, appeal requests, and medical information related to your case.
Take Detailed Notes and Set Response Deadlines
Keep notes about the dates/times of all calls and other communication, names of people with whom you had conversations, and details of all conversations. Ask about and make notes of any set deadlines for expected responses or information from your insurer.
Sample letter to request an internal appeal
Add your own information when you see italics below.
Your Name
Your Address
Date
Address of the Health Plan’s Appeal Department
Re: Name of Insured
Plan ID#:
Claim #:
To Whom It May Concern:
I am writing to request a review of your denial of the claim for treatment or services provided by name of provider on date provided.
The reason for the denial was listed as (reason listed for denial), but I have reviewed my policy and believe the service should be covered. Here is where you may provide more detailed information about the situation. Write short, factual statements. Do not include emotional wording. If you’re including documents, include a list of what you’re sending here.
If you need additional information, I can be reached at telephone number and/or e-mail address. I look forward to receiving your response as soon as possible.
Sincerely,
Signature
Typed Name
Telephone Number
Email address
