It can be frustrating when you are recovering from treatment, no matter how small, that your insurance claim was denied. There can be many reasons for this denial, and before getting frustrated or angry, follow the steps mentioned in this article to understand where you stand. Once you do, you can focus on appealing and overturning the denial.

Step # 1 – Why Was Your Claim Denied?

The first step is to get all the details about your denial, and you can get a copy of the denial letter. Typically, the most common reasons for rejection are simple computer or human errors, such as mismatched or incomplete information. Furthermore, the doctor or the insurance didn’t think the treatment or procedure was necessary and came under the coverage guidelines.

There can also be a mistake where you didn’t go to a doctor from the network, or the report made a mistake in making connections. Finally, you can also fully utilize your coverage's maximum limit.

Don’t forget to check your remaining time for the appeal and the points that must be included in the plea.

Step # 2 – Communicate with Your Insurance Agent

Your agent will now be the trove of information as he knows the ins and outs and has been through similar claims before. He can help you with documentation, getting more details of the denial reasons, and more. Whatever steps he tells you or forms that you need to fill out, carefully follow them to the letter. You can make a much stronger case.

One important thing to know here is to use the proper terms subsequently as you follow through the steps mentioned below. For example, if you still need to take the treatment you plan to and it is denied, it is called a prior authorization denial. But if you have taken the treatment, then in this case, it is called a claim denial.

Step # 3 – Discuss the Case with the Doctor’s Office

Following step 1, you can discuss with your doctor if the mistake was on their end, which will expedite the process much quicker. All they would need to do now is re-submit the application and get your claims approved. 

If, in the case, the denial was due to the medical relevancy of your claim, then you can discuss with the doctor why it is crucial. An explanation letter about the necessity of your treatment is the fastest way to overturn the denial.

This can be one of the most crucial steps of your appeal as you need to put together compelling evidence, which is only accessible with the support of your medical office.

Step # 4 – Working on the Paperwork

Make sure to collect and arrange the paperwork mentioned in the 2nd step. The most typical documents included are as follows.

· The denial letter that you have received from your insurance company.

· Please include billing information and all the bills you have incurred in the past related to the service claim denied.

· Any communication you have had with your insurance agent and doctor. This includes notes on calls and email threads as well.

· You may also include supplementary documents during step 3 to strengthen your case.

· Any other supporting documentation, such as your health records, previous letters, or doctor reports.

After you are done with completing the paperwork, show it to your agent to ensure there isn’t anything missing.

Step # 5 – Submitting an Appeal to the Insurance Provider

Once all the documentation is ready and you have all the forms according to your agent’s instructions, start the appeal process. It would be best to make an internal appeal to your insurance company to reconsider the initial decision. The best scenario is that they reverse the judgment due to errors or missing information. The most straightforward appeal document should include the following necessary information.

· The reason behind the denial of the service.

· Mention your claim number, which you can find on the denial of the service letter you received.

· Now mention why the decision should be reconsidered and reversed. Here, you must attach the necessary documents supporting your evidence.

· Your medical history outlines your condition and why you and your doctor deemed this treatment necessary.

· All of the supporting documentation mentioned in Step 4 should be included.

As we said, appeal as simply and concisely as possible with all the critical documents and never present with strong emotions. Keep your emotions out of the appeal document.

Step # 6 – Waiting for the Results

While your insurance provider needs to decide on your insurance plea, it varies depending on certain circumstances.

· If you are appealing for a service or treatment that you will undertake soon, the decision must be made within 30 days.

· Now, if you have already taken the treatment and applied for the appeal, they must decide within 60 days of your request.

· Finally, in extreme cases where you must undergo treatment under urgent care, the company or your insurance provider must make a critical decision within 72 hours.

Step # 7 – Re-appeal Through an External Review

If, in this case, your initial appeal to reverse the denial decision isn’t thriving as you applied through internal review, then external is the best option. You can now discuss your case with a 3rd party to make an external review on your behalf. They will investigate the matter honestly and inform you about their findings. 

Final Comments

It is clear from the information that we have dispensed in this article that you need to be fully informed of your policy regulations. You are good to go if you know your limitations and which doctors, hospitals, and treatments your plan covers. You won't be accidentally taking a treatment that isn't covered, and your application won't be denied. So keep these aspects in mind, whether taking a medicine or appealing for a denial of service.