Filing Health Insurance Appeals
Has your insurance company denied your medical claim or failed to pay your claim the way you think it should? You may be able to resolve the issue by filing an appeal.
The appeals process is used when your insurance company denies a benefit or does not make full payment on a benefit that you and your doctor believe you need.
By law, health insurance companies are required to have procedures in place to address concerns from policyholders. The appeals process is used if you receive an adverse benefit determination, that is when your insurance company denies a benefit or does not make full payment on a benefit that you and your doctor believe you need. This can happen for many reasons, including:
- The benefit isn't covered by your health insurance plan;
- You received the service(s) from an out-of-network health provider or facility;
- The service is not medically necessary;
- The service is specifically excluded from your policy;
- The service is a covered service at an in-network provider, but you and your insurer disagree about how much you should pay; or
- You are no longer eligible for coverage under that health insurance plan.
If you believe you've received an adverse benefit determination that you don't think is right, read our appeal guide for more information on your next steps.