Claim Appeal Process: Tips for Success

The claim appeal process allows you to challenge an insurance company’s decision to deny your claim. In this blog post, we will discuss how the claim appeal process works and provide tips for submitting a successful appeal.

What is the Claim Appeal Process?

The claim appeal process gives policyholders the right to request a review of an insurer’s decision to deny, limit, or terminate benefits.

If an insurance company denies your claim for benefits either partially or fully, you have the option to appeal this decision.

The claim appeal process allows both you and the insurer another opportunity to review the claim and present additional evidence or documentation.

This is important because the initial denial may have been due to an oversight, missing information, or misunderstanding. By going through the claim appeal process, the final decision on your claim can potentially be reversed.

How Does the Claim Appeal Process Work?

Most insurance companies have a two-step appeal process, but the specific procedures and deadlines may vary depending on your state regulations and type of insurance. Here are the typical stages of the claim appeal process:

1. First Level or Internal Appeal

For your first appeal, you will need to submit a written request to the insurance company within a certain number of days from the date of the claim denial letter.

This is usually 60-180 days. In your letter, explain why you disagree with the denial decision and include any new documentation to support your claim.

The insurer will then have 30-60 days to review your appeal and send you their decision. They may uphold, reverse, or partially reverse the original denial.

2. Second Level or External Appeal

If the insurer upholds its decision after the first appeal, you have the option to request an external or second-level appeal.

At this stage, an independent review organization not affiliated with the insurance company will review your full case file.

To start a second-level appeal, submit your appeal request within a specified timeframe, usually 60-180 days from the internal appeal denial letter.

The external review organization must decide within 45-90 days. Their ruling is binding for the insurance company.

Tips for a Successful Appeal

To increase your chances of a favorable decision, here are some tips to keep in mind when submitting a claim appeal:

• Meet all submission deadlines- Most states require appeals to be filed within strict timeframes.
• Provide thorough documentation- Submit any new medical records, bills, test results, or documentation left out of the initial claim.
• Cite policy provisions- Highlight the specific policy coverage provisions and definitions that support your appeal.
• Explain inconsistencies- Address areas where the insurer’s rationale appears to contradict the policy or your medical condition and treatment.
• Obtain support letters- Submit letters from your doctor or other medical experts explaining why the denial was incorrect or unjustified.
• Request a conference call- Ask for a phone meeting to directly discuss complex issues with the appeals specialist or medical director reviewing your case.
• Consider legal assistance- For denied claims over $1,000, you may want to hire an attorney experienced in insurance appeals.
• Explore external resources- For auto, home, or health plans, free assistance may also be available through your state Department of Insurance.

By thoroughly addressing the reasons for denial and providing all supporting records, you greatly increase the chances that your claim will be approved on appeal.

However, be prepared for the possibility that the denial may be upheld, at which point you have exhausted your administrative remedies.

What Happens if the Appeal is Denied?

If your claim appeal is denied by the insurance company or external review organization, this typically marks the end of the administrative claim appeal process provided under your insurance policy and state law.

However, you still have a couple of options to potentially receive compensation at this stage:

File a Lawsuit

For disputed claims over a certain amount, usually $25,000-$50,000, you have the option to file a civil lawsuit against the insurer in court to argue breach of contract.

You will need to prove the claim was wrongly denied under the terms of the insurance policy. This can be an expensive process with no guarantee of success or reimbursement of legal fees.

Check for Ombudsman Services

Your state department of insurance may have an ombudsman program that can investigate denial decisions and work with insurers to potentially resolve claim disputes, often through negotiation rather than litigation.

Submitting a complaint to the state ombudsman is typically free of charge, although they cannot force the insurer to reverse a denial.

In summary, fully exhausting the insurance claim appeal process gives you the best chance to overturn a denied claim without taking more drastic legal actions.

With strong documentation and a clear explanation of your position, you have a fair shot at a more favorable decision on appeal. Let me know if you have any other questions!

A few Additional aspects of the Claim Appeal Process

Types of Appeals

The internal first-level appeal is typically a paperwork appeal where you submit additional documentation.

The external second-level appeal may involve an in-person hearing by phone or videoconference where you can verbally explain your case to the review committee.

Time Extensions

Most states allow you to request one 30-day extension if you need more time to gather supporting documents for your appeal. It’s best to submit extension requests well before the appeal deadline.

Medicare Appeals

For Medicare claims, there is a four-stage claim appeal process including redetermination by the insurer, reconsideration by a qualified independent contractor, administrative law judge hearing, and the Medicare Appeals Council.

Auto & Homeowners Claims

Property insurance appeals often involve damage assessments, estimates, photos, contractor estimates, etc. to prove the initial evaluation didn’t properly address the full extent of repairs needed.

Long Term Disability

Challenging denials of disability benefits appeals require including medical records, doctor’s assessments of functional limitations, and evidence you cannot perform your own or any other occupation to qualify.

Tips for Communicating Your Case

Use clear, straightforward language explaining why the denial is wrong based on the policy terms and your circumstances.

Remain polite and avoid adversarial language that could negatively impact the reviewer’s perception.

Appeal Outcomes

In addition to upholding or overturning the denial, appeals decisions can sometimes result in approving benefits but for a shorter period than claimed or with certain treatments or services excluded. A partial win is still better than a complete loss.

Frequently Asked Questions and Answers

Here are some frequently asked questions about the insurance claim appeal process:

Question: What is the deadline for filing an appeal?

Answer: Most states require first-level internal appeals to be filed within 60-180 days of receiving a claim denial letter. Check your insurance documents or contact your insurer for specific timeframes.

Question: Can I appeal if some of my claim was approved?

Answer: Yes, you can file an appeal to challenge denials or limitations on specific services, procedures, periods, or benefit amounts even if other parts of your claim were paid out.

Question: Do I need to submit new documentation for an appeal?

Answer: Providing additional documentation not included with your initial claim is highly recommended, such as medical records, invoices, estimates, etc. This gives the appeals reviewer a fuller picture to potentially overturn the original decision.

Question: What if I miss the appeal deadline?

Answer: Failure to file an appeal within the required timeframe will result in the denial becoming binding. However, it’s worth requesting an extension if you have a valid reason for missing the deadline such as an ongoing medical issue.

Question: Can an attorney represent me in the appeal?

Answer: While not required, representation by a legal professional can be advisable for complex appeals or larger claim amounts. Attorneys know how to effectively argue the merits of the case under insurance law.

Question: What happens if my first appeal is denied but new information arises?

Answer: You may be able to submit new documentation and request reconsideration or file a second-level appeal, depending on timing and the specific claim appeal process. Consult your insurer for your options.

Question: How long does the claim appeal process usually take?

Answer: First-level internal appeals typically take 30-60 days for a decision. Second/external appeals are 45-90 days on average but can vary by state laws and individual review timelines.

Question: If both appeals fail, what are my options?

Answer: You can consider filing a civil lawsuit if the claim exceeds the small claims limit or contacting your state department’s insurance ombudsman for dispute resolution assistance.