A health insurance company is just like any other business: They screw up. About 7 percent of claims are initially rejected by health insurers. Here's how you work the system.

This is for you: If you've gotten a notice of denial on a health insurance claim and believe that the treatment should have been covered.

Hands-on time: If you have everything you need, it shouldn't take more than an hour or two to put together the actual appeal. Gathering the necessary info may take longer.

Total time: From a few weeks to a few months or longer, depending on the number of times you appeal.

Cost: $0, unless your appeal is particularly complicated, in which case you might consider hiring a patient advocate to work on your case. Under some circumstances and with some organizations (the Patient Advocate Foundation, for instance), there's no charge. (Other claims professionals may charge $30 to $160 per hour or more.) Find a program in your area here.

What you should know:

• Everything there is to know about your condition, including what your doctor is recommending and why he's recommending it. If you don't have a clear understanding of this, ask your doctor to put it in writing for you (and for your insurance company).


• What kind of insurance you have. (This isn't as simple as you think.) If you're covered through your employer, call the benefits manager and have him or her explain the coverage you have. Depending on how your insurance works, the appeals process may involve the benefits manager instead of the insurance company-your benefits manager should be able to tell you how it works.

What you'll need:

• The letter from your health insurer denying your claim.


• Your health insurance documentation or booklet. If you don't have yours, request a copy in writing from your plan administrator.


• Details of the appeals process at your insurance company, including how long you have to file an appeal (30 days, for instance). Your insurance company may require you to call a specific phone number to start the process or they may require a written appeal, in which case you'll need an address.


• Names and numbers of anyone at your doctor's office who can provide you with any information you might need (usually the department responsible for submitting insurance claims for payment).

What to do:

1. Get a folder. In that folder, keep the following:

• All correspondence from your insurance company, including any letters denying your claim.


• A record of your dealings with your insurance company, including phone calls and letters. Take note of dates, times of day, and the names of anyone you talk to.


• Any documentation from your doctor regarding the recommended treatment or therapy.

2. Write an appeal letter. It should include the following:

• Your name, insurance specifics (policy number, group number), and any claim number or other identification assigned to your case


• The insurance company's stated reason for denial


• A simple summary of your condition and the recommended treatment


• Why you think the insurance company made a mistake (this should be based on facts, not information you looked up on Wikipedia)


• Your request. Are you asking the company to reconsider their denial and cover the treatment? Say so.

3. Include with your appeal letter:

• A letter from your doctor or specialist stating that the treatment is necessary and why


• A copy of any relevant information from your medical record


• Copies of clinical journal studies or articles that back up your treatment and its effectiveness, if you have them

4. Be firm, factual, and nice. Don't get emotional. (And don't call anyone names. Really.)

5. Send your appeal by registered or certified mail or another trackable method so you can prove that the insurance company received it.

6. Wait. This really is the hardest part. If your health insurance plan doesn't specify how long the company has to respond to an appeal, ask the company itself or your benefits manager when you should expect a response.

7. Approved? Fantastic. Request the approval in writing and find out if there are any restrictions that go along with it.

8. Denied again? Read the language of the second letter. Does it give the same reason for the denial as before, or a new reason? (If you appeal again, make sure you respond to the reason stated in the second letter.)

9. Feel free to try, try again-there are multiple levels to the appeals process at most companies, and your second letter might reach someone higher up on the food chain.

10. If your insurer continues to deny your appeals, you can seek an independent review through your state insurance regulator (start here) or consider consulting an attorney.

To learn more:
Your Guide to the Appeals Process (Patient Advocate Foundation)

Who helped: Erin Moaratty, chief of external communications for the Patient Advocate Foundation


Did you do it? Tell us what worked or share other tips in the comments below.


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