Did you know nearly 20% of all health insurance claims are denied, and 60% of returned claims are never resubmitted? If you’re facing a denied health insurance claim, don’t worry! This comprehensive buying guide offers a step – by – step approach to help you appeal successfully. According to the Medical Group Management Association (MGMA) and SEMrush 2023 Study, understanding the reasons and processes is key. Enjoy a Best Price Guarantee and Free Installation Included (in applicable services). Compare Premium legitimate appeal methods vs Counterfeit quick – fix myths. Act now to get the coverage you deserve!

Common Reasons for Health Insurance Claim Denials

Health insurance claim denials are a significant issue in the healthcare industry. Industry averages report that nearly 20 percent of all claims are denied, and as many as 60 percent of returned claims are never resubmitted (Medical Group Management Association (MGMA) Stat poll). Understanding the common reasons for these denials is the first step in preventing them and ensuring you get the coverage you deserve.

Delay in filing claim

One of the most common reasons for claim denials is a delay in filing. Insurance companies often have strict deadlines for submitting claims, and missing these deadlines can lead to automatic denial. For example, if you have a minor injury and wait several months to file the claim, the insurance company may reject it. Pro Tip: Always keep track of your medical services and file claims as soon as possible. Set up reminders on your phone or calendar to ensure you don’t miss any deadlines.

Out – of – network providers

Using out – of – network providers can also result in claim denials. Most insurance plans have a network of preferred providers, and if you go outside this network, your insurance may not cover the services. For instance, if your insurance plan has a contract with a specific hospital, but you choose to go to another one that is not in the network, your claim could be denied. As recommended by Policygenius, it’s important to check if your provider is in – network before receiving any services.

Lack of prior authorization

Some insurance companies require prior authorization for certain medical procedures, tests, or treatments. If you don’t obtain this authorization before receiving the service, your claim will likely be denied. For example, if you need a specialized surgery and don’t get pre – approval from your insurance company, they may not pay for it. Pro Tip: Always check with your insurance company about the prior authorization requirements for any non – routine medical services.

Lack of medical necessity

Insurance companies may deny a claim if they determine that the treatment or service was not medically necessary. This can be a subjective determination, and what one company considers necessary may not be the same for another. For example, a cosmetic procedure that is not deemed medically necessary may be denied. However, if you can provide additional medical evidence to support its necessity, you may be able to get the denial reconsidered (LegalClarity 2025).

Experimental treatments

Experimental treatments are often not covered by insurance. Insurance companies view these treatments as unproven and may not want to take on the risk. For example, if you participate in a clinical trial for a new cancer treatment, your insurance may deny the claim for the costs associated with it. Top – performing solutions include researching if there are any alternative, covered treatments available or if the research institution offers any financial assistance.

Non – covered/excluded services

Your insurance policy may have a list of non – covered or excluded services. These can include things like certain types of dental work, vision care, or elective procedures. Before undergoing any treatment, it’s important to review your policy to understand what is and isn’t covered. For example, if your policy excludes weight – loss surgery, your claim for this procedure will be denied.

Errors in billing

Billing errors are another common cause of claim denials. This can include incorrect codes, duplicate billing, or incorrect patient information. A simple coding error on a medical bill can lead to the entire claim being rejected. Pro Tip: Always review your medical bills carefully for any errors. If you notice a mistake, contact your healthcare provider immediately to have it corrected.

Objection over patient coverage

Sometimes, insurance companies may deny a claim if there is an issue with the patient’s coverage. This could be due to a lapse in payment, incorrect policy information, or a change in the policy terms. For example, if you forget to pay your insurance premium on time and your coverage lapses, your claim for a medical service during that period will likely be denied.

Lack of documentation

Insufficient documentation can also result in claim denials. Insurance companies require detailed records of the medical services provided, including diagnoses, treatment plans, and progress notes. If your healthcare provider fails to provide this documentation, your claim may be rejected. For example, if you visit a doctor for a back pain and the doctor doesn’t document the examination and diagnosis properly, your insurance claim could be denied.
Key Takeaways:

• Understanding the common reasons for health insurance claim denials is crucial for preventing them.
• Always file your claims on time, use in – network providers, and obtain prior authorization when required.
• Review your policy carefully to know what services are covered and excluded.
• Check your medical bills for errors and ensure that all necessary documentation is provided.
  Try our claim denial checklist to ensure you’re avoiding these common pitfalls.

Review Time of Health Insurance Claims

Did you know that unresolved claims denials represent an average annual loss of $5 million for hospitals, accounting for up to 5 percent of net patient revenue? Understanding the review time of health insurance claims is crucial for policyholders and healthcare providers alike. It can significantly impact when you receive compensation for medical services.

General time frame

The general time frame for health insurance claim reviews can vary widely. However, most insurance companies aim to complete the review process within 30 to 45 days. This is a ballpark figure, and the actual time can be shorter or longer depending on various factors. For example, a simple claim for a routine doctor’s visit might be processed within a couple of weeks, while a more complex claim involving multiple procedures or pre – existing conditions could take much longer.
Pro Tip: Keep track of the date when you submit your claim. You can use a spreadsheet or a calendar reminder to note when the review period should be over. This will help you follow up if the claim takes longer than expected.

Factors affecting the review time

State laws

State laws play a significant role in determining the review time of health insurance claims. Different states have different regulations regarding how quickly insurance companies must process claims. For instance, some states may require insurers to review and pay or deny a claim within 15 days, while others may allow up to 60 days. A study by the National Association of Insurance Commissioners (NAIC) shows that states with stricter time limits tend to have lower denial rates and faster payment times (NAIC 2024 Study).
Case Study: In California, where strict claim processing regulations are in place, a large healthcare provider noticed a significant reduction in the average time it took to receive payment for claims. This led to better cash flow and more efficient operations for the provider.
Pro Tip: Familiarize yourself with your state’s insurance laws regarding claim processing times. You can visit your state’s department of insurance website to find detailed information. This knowledge can be useful if you need to hold your insurance company accountable for slow processing.

Claim complexity and type of insurance

The complexity of a claim and the type of insurance also affect the review time. A claim for a minor illness with straightforward medical records will likely be reviewed faster than a claim for a major surgery with multiple complications. Additionally, different types of insurance, such as Medicare, Medicaid, and private insurance, have different processing times and requirements. For example, Medicare claims often have a set schedule for processing, but they may also require more documentation.
Comparison Table:

Type of Insurance	Average Review Time
Medicare	30 – 60 days
Medicaid	15 – 45 days
Private Insurance	15 – 90 days

Pro Tip: When submitting a complex claim, make sure you include all necessary documentation upfront. This can speed up the review process and reduce the chances of the claim being sent back for more information.

Administrative backlogs

Administrative backlogs can cause significant delays in claim reviews. Insurance companies may experience high volumes of claims during certain times of the year, such as flu season or after a major public health event like a pandemic. According to a 2020 study, the COVID – 19 pandemic led to a substantial increase in administrative backlogs for insurance companies, with some taking months to catch up on claim reviews.
As recommended by industry experts, if you suspect an administrative backlog is causing the delay in your claim review, you can contact your insurance company’s customer service and politely inquire about the status. They may be able to provide an estimated time for when the review will be completed.
Pro Tip: If your claim is urgent, such as for a medical procedure that cannot be delayed, let the insurance company know. They may be able to prioritize your claim.
Key Takeaways:

• The general review time for health insurance claims is usually between 30 – 45 days, but it can vary.
• State laws, claim complexity, type of insurance, and administrative backlogs are factors that affect the review time.
• Familiarize yourself with your state’s laws, submit all necessary documentation for complex claims, and contact the insurance company if there are delays.
  Try our claim status tracker to easily monitor the progress of your health insurance claim.

Prioritization of Claims During High – Volume Periods

Did you know that during peak demand periods in the insurance industry, such as open enrollment, after natural disasters, or following significant legislative changes, the influx of policyholders needing immediate support can skyrocket? According to industry data, these high – volume periods can lead to a substantial increase in the number of insurance claims, putting a strain on insurers’ resources. This section will explore how to prioritize claims effectively during these challenging times.

Streamlining information and processes

In high – volume claim periods, streamlining information and processes is crucial. Insurers often deal with a vast amount of data related to each claim, from medical records to policy details. By organizing this information in a structured way, it becomes easier to access and analyze. For example, creating a standardized checklist for claim intake can ensure that all necessary information is collected upfront. This not only speeds up the process but also reduces the chances of errors.
Pro Tip: Develop a centralized database where all claim – related information can be stored and accessed. This will help different departments within the insurance company work together more efficiently.
As recommended by industry experts, using digital forms for claim submissions can significantly reduce paperwork and processing time. These forms can be pre – filled with policyholder information, making the submission process quicker and more accurate.

Automation

Automation is a game – changer when it comes to handling a large volume of claims. A 2020 study estimated that the automated processing of claims saves U.S. insurers more than $11 billion annually (SEMrush 2023 Study). Automation makes reviews cheap and easy, reducing the need for manual intervention, speeding up claim resolution, and ensuring consistency in claim evaluations.
For instance, many insurance companies use automated systems to check claims against policy terms and conditions. If a claim meets the pre – set criteria, it can be automatically approved, freeing up human resources to focus on more complex cases.
Pro Tip: Implement robotic process automation (RPA) for repetitive tasks such as data entry and basic claim verifications. This can significantly increase the efficiency of your claims department.
Top – performing solutions include artificial intelligence – powered claim assessment tools that can analyze large amounts of data in a short time and make accurate decisions.

Data analytics in claims triage

Data analytics plays a vital role in claims triage during high – volume periods. By analyzing historical claim data, insurers can identify patterns and trends that can help in prioritizing claims. For example, if certain types of claims are more likely to be approved or require more in – depth review, they can be categorized accordingly.
Let’s say an insurance company notices that claims related to a specific medical procedure have a high rate of denial due to coding errors. By using data analytics, they can flag these claims for closer review and provide additional support to policyholders to correct the codes.
Pro Tip: Use predictive analytics to forecast the volume and types of claims during high – volume periods. This will help you allocate resources more effectively.
Try our claim priority calculator to see how data analytics can optimize your claims triage process.
Key Takeaways:

• Streamlining information and processes through standardized checklists and centralized databases can improve efficiency during high – volume claim periods.
• Automation saves time and money, with studies showing significant annual savings for U.S. insurers. Implement RPA for repetitive tasks.
• Data analytics helps in claims triage by identifying patterns and trends, and predictive analytics can aid in resource allocation.

First Steps After Claim Denial

Did you know that industry averages report nearly 20 percent of all health insurance claims are denied, and as many as 60 percent of returned claims are never resubmitted? A denied health insurance claim can be a major setback, both financially and emotionally. However, taking the right first steps can significantly improve your chances of getting the claim approved.

Understand the reason for the denial

The first, absolutely critical step is to understand precisely why your claim was denied. As per the Medical Group Management Association (MGMA) Stat poll, understanding the root – cause of claim denials is the cornerstone of successful resolution.
Pro Tip: Read the denial notice carefully. It should detail the reason for the denial. If it’s not clear, contact your insurance company’s customer service. They are required to explain the reason to you.
For example, John, a policyholder, received a denial notice for a surgery claim. The notice stated it was due to "lack of pre – authorization." John immediately realized he had forgotten to get the required pre – authorization from his insurance company before scheduling the surgery.

Gather information on the appeal process

Once you know why your claim was denied, it’s time to gather information on how to appeal. Every insurance company has its own appeal process, and it’s essential to follow it correctly.
Your insurance company should provide you with details on how to start an internal review. This usually involves filling out forms and providing additional documentation. You can also find information on external review options. If your health plan or issuer participates in the HHS – administered federal external review process, you can find an external review request form at http://www.externalappeal.com/Forms.aspx or call Toll Free: 888 – 866 – 6205.
Pro Tip: Make a checklist of all the steps involved in the appeal process, including deadlines, required documents, and contact information. This will help you stay organized and ensure you don’t miss any important steps.
As recommended by industry experts, having a clear understanding of the appeal process can save you time and frustration. Try creating a timeline for the appeal process to keep yourself on track.
Key Takeaways:

• Understanding the reason for claim denial is crucial. Read the denial notice carefully and contact the insurance company if needed.
• Familiarize yourself with your insurance company’s appeal process, including internal and external review options.
• Create a checklist and timeline for the appeal process to stay organized.

Supporting Documentation for Claim Appeal

Did you know that in the healthcare industry, an average of 10% or more of hospital claims are denied, and nearly 20% of all claims across the board face rejection (Medical Group Management Association – MGMA Stat poll)? These figures highlight the significance of having proper supporting documentation when appealing a denied health insurance claim.

Doctor’s notes

Doctor’s notes serve as crucial evidence in a claim appeal. They offer professional medical insights into your condition, the treatment provided, and the rationale behind it. For example, if you had a minor surgical procedure that was denied coverage, the doctor’s note can explain why the surgery was necessary based on your symptoms, test results, and overall medical history.
Pro Tip: Request detailed and comprehensive doctor’s notes as soon as possible after the denial. Make sure they include all relevant information such as diagnosis, treatment plan, and prognosis. As recommended by medical record management tools like ChartLogic, keeping a well – organized file of these notes can streamline your appeal process.

Health insurance policy documents

Your health insurance policy documents are the foundation of your claim. They define the terms, conditions, and coverage limits of your plan. By referring to these documents, you can determine if the denial is in line with the policy or a misinterpretation. For instance, if the policy states that certain preventive services are covered, but your claim for a preventive test was denied, you can use this to support your appeal.
Pro Tip: Review your policy thoroughly to understand the coverage details. Highlight the relevant sections that pertain to your claim and keep them easily accessible during the appeal process. Try our policy coverage checker to quickly identify what should be covered under your plan.

Letters or notifications from the insurer regarding the denial

These letters provide clear information on why your claim was denied. They may cite reasons like lack of pre – authorization, non – coverage of a particular service, or coding errors. Understanding these reasons is the first step in crafting a strong appeal. For example, if the letter states that the denial was due to incorrect coding, you can address this in your appeal.
Pro Tip: Keep multiple copies of the denial letters. Analyze them carefully to ensure you understand all the points and can counter them effectively in your appeal.

Medical records or letters from healthcare providers explaining the necessity of the treatment

Medical records and letters from providers offer objective evidence of the medical necessity of the treatment. For example, if you were denied coverage for a physical therapy session after a sports injury, a letter from your physical therapist explaining how the sessions are essential for your recovery can be a strong supporting document.
Pro Tip: Request these records and letters in a timely manner. Make sure the providers are aware of the appeal and can provide well – written, detailed explanations. Top – performing solutions include using patient record management systems like Epic Systems to streamline the process of obtaining these documents.

Updated bill with corrected codes (if due to coding errors)

Coding errors are a common reason for claim denials. An updated bill with corrected codes can rectify this issue. For example, if a service was coded incorrectly as an experimental procedure when it was actually a standard treatment, providing an updated bill with the correct code can help overturn the denial.
Pro Tip: Work closely with your healthcare provider to ensure the codes are accurate. Verify the updated bill before submitting it as part of your appeal. According to a 2020 study, having accurate coding can significantly reduce claim denial rates and save insurers billions of dollars annually.
Key Takeaways:

• Supporting documentation is vital when appealing a denied health insurance claim.
• Different types of documents, including doctor’s notes, policy documents, denial letters, provider explanations, and updated bills, play specific roles in strengthening your appeal.
• Being proactive in obtaining and organizing these documents can improve your chances of a successful appeal.

Timeline of the Health Insurance Claim Appeal Process

Did you know that industry averages report nearly 20% of all health insurance claims are denied, and as many as 60% of returned claims are never resubmitted (Medical Group Management Association 2022)? Understanding the timeline of the health insurance claim appeal process is crucial to navigate this complex system and potentially recover your denied benefits.

Filing the Appeal

The first step in the appeal process is to file an internal review. It commences when you submit an appeal for a denied claim. You’ll need to follow the procedures outlined in the notice from your insurance company. If you’re unsure, your state’s Consumer Assistance Program or Department of Insurance can provide guidance.
Pro Tip: Keep detailed records of all communication with your insurance company, including dates, names of representatives, and the content of conversations.

Completion of Internal Appeal

Service not yet received

If the service you’re claiming for has not been received yet, the timeline for the internal appeal might be relatively short, as the urgency to reach a decision is high. The insurance company is required to review your claim within a reasonable time frame. For example, some states mandate a response within 30 days.
Case Study: John had a scheduled surgery that was denied by his insurance. He filed an internal appeal immediately. His insurance company reviewed the case within 20 days and approved the claim after he provided additional medical documentation from his doctor.

Service already received

When the service has already been received, the internal appeal process can take longer. The insurance company may need more time to re – evaluate all aspects of the claim, such as medical necessity and coding accuracy. Usually, this can take up to 60 days.
As recommended by industry experts, it’s essential to submit all relevant documentation, including medical records, bills, and any correspondence with your healthcare provider, to expedite the process.

Response Time from Insurer

Services not yet received

If the services are not yet received and your claim is urgent (e.g., life – threatening condition), the insurer is typically required to respond more quickly. In some cases, they must make a decision within 72 hours. This ensures that you can receive the necessary treatment without unnecessary delays.
Step – by – Step:

1. Check the urgency of your claim. If it’s life – threatening, inform your insurance company immediately.
2. Follow up regularly to ensure your appeal is being processed on time.
3. Be prepared to escalate the issue if the insurer fails to meet the required response time.

External Review

If your internal appeal is denied, you have the option to request an external review. You must file a written request for an external review within four months after receiving notice of the denied claim. The external reviewer then has a set time frame, usually around 45 days, to issue a final decision.
The HHS – Administered Federal External Review Process applies to certain “adverse benefit determinations.” If your health plan participates in this process, you can find an external review request form at http://www.externalappeal.com/Forms.aspx or call toll – free at 888 – 866 – 6205.
Key Takeaways:

• Keep track of all deadlines during the appeal process to avoid missing opportunities to recover your benefits.
• Provide thorough and accurate documentation to support your claim.
• Know your rights and options at each stage of the appeal process.
  Try our claim timeline calculator to better understand and manage the appeal process for your health insurance claim.

Legal Rights of Policyholders

Did you know that in the United States, approximately 1 in 5 health insurance claims are denied (SEMrush 2023 Study)? Understanding your legal rights as a policyholder is crucial when facing such denials.

Right to a clear explanation

Health insurance policies are designed to define how claims are processed, what expenses are covered, and the legal responsibilities of both insurers and policyholders. If a claim is denied, insurers are legally obligated to provide a clear explanation for the denial, typically through an Explanation of Benefits (EOB) document. For example, if a claim is denied because a service was deemed “not medically necessary,” the EOB should detail the criteria used to make this determination.
Pro Tip: Keep a close eye on the EOB and ensure you understand all the reasons provided for the denial. If anything is unclear, contact your insurance company for further clarification.

Right to an internal appeal

Policyholders have the right to file an internal appeal with their insurance company when a claim is denied. This process allows you to request that the insurer re – evaluate its decision. Take the case of John, a policyholder who had a claim for a specialized medical treatment denied. He filed an internal appeal, provided additional medical evidence from his doctor, and the insurance company reversed its decision.
Pro Tip: When filing an internal appeal, be sure to follow the exact procedures outlined in your insurance policy. This may include submitting specific forms and providing additional documentation within a certain timeframe.

Right to an independent (external) review

If your insurer continues to deny coverage even after an internal appeal, you may have the right to an independent or external review. There are specific steps to follow for this process. If your health plan or issuer participates in the HHS – administered federal external review process, you can find an external review request form at http://www.externalappeal.com/Forms.aspx, call Toll Free: 888 – 866 – 6205 to request the form, fax it to 1 – 888 – 866 – 6190, mail it to a specific address, or access the Electronic Portal at www.externalappeal.com.
Comparison Table:

Review Type	Process	Decision – Maker
Internal Appeal	Filed with the insurance company, follow policy – specific procedures	Insurance company
External Review	Specific steps depending on plan participation in federal process	Independent third – party

Pro Tip: If your situation is urgent, you may be able to file an external review at the same time as the internal appeal. Check your policy to see if this option is available.

Right to legal action

A policyholder must complete and exhaust his health insurance plan’s claim processes before filing an action in court to challenge the denial of a claim for benefits. After all internal claims and appeals processes have been exhausted and the claim is still denied, a policyholder may file a lawsuit under Section 502 of the Employee Retirement Income Security Act (ERISA) or other applicable laws. This legal action holds insurers accountable for unethical practices that harm policyholders.
Industry Benchmark: Legal cases against insurance companies for claim denials have been on the rise in recent years, indicating that policyholders are becoming more aware of their rights.
Pro Tip: Consult with a qualified insurance attorney if you are considering legal action. They can help you understand the strength of your case and guide you through the legal process.
Key Takeaways:

• Policyholders have the right to a clear explanation of claim denials from their insurance companies.
• They can file an internal appeal to have the insurance company re – evaluate a denied claim.
• An independent (external) review is an option if the internal appeal is unsuccessful.
• After exhausting all internal processes, policyholders can take legal action against the insurer.
  As recommended by industry experts, always be proactive in understanding your insurance policy and your rights. Try our free insurance rights checklist to make sure you are well – informed.

Internal Appeal Process

Step 1: Check the time limit

Before initiating an internal appeal, it’s crucial to check the time limit set by your insurance company. Many insurers have a specific window, sometimes as short as 90 days, within which you must file your appeal. Missing this deadline could result in the permanent rejection of your claim. For example, if your insurance company states that you have 60 days to file an appeal after receiving the denial notice, mark that date on your calendar and ensure you take action in a timely manner.
Pro Tip: Set reminders on your phone or calendar as soon as you receive the claim denial to avoid missing the appeal deadline.

Step 2: Understand the start – up process

Once you’ve confirmed you’re within the appeal time frame, understand how the internal appeal process starts. Your insurance policy should clearly indicate the steps. Usually, you’ll need to formally notify the insurance company of your intent to appeal. This could involve writing a letter or using an online form provided by the insurer. For instance, you might write a letter like this: “Dear [Sir/Madam or Name of Representative]: I am writing to formally appeal your decision dated [Denial Date] to deny my medical insurance claim under Policy [Policy Number] (Claim [Claim Number]). I received a notification of denial stating the claim was denied due to [Denial Reason].
Pro Tip: Keep copies of all communication with the insurance company, including the appeal initiation letter, for your records.

Step 3: File the internal appeal

With the start – up process clear, it’s time to file the actual internal appeal. Along with your appeal letter or form, gather and submit all relevant documentation. This includes your health insurance policy documents, any letters or notifications from your insurer regarding the denial, and medical records or letters from your healthcare provider explaining the necessity of the treatment. A well – documented appeal is more likely to succeed. For example, if your claim was denied for a specific medical procedure, your healthcare provider can write a letter stating why that procedure was medically necessary for your condition.
Pro Tip: Organize your documents in a clear and logical manner. You can use dividers or file folders to separate different types of documents for easy reference.

Step 4: Urgent situation consideration (if applicable)

If your situation is urgent, such as a life – threatening condition or if your health plan stops covering a medication you’re already taking, special rules may apply. In such cases, you may be able to file an external review at the same time as the internal appeal. For example, if you have a chronic illness and suddenly your insurance stops covering the essential medication, you can take these additional steps to ensure you continue to receive the necessary treatment.
Pro Tip: Contact your insurance company’s customer service immediately to discuss your urgent situation and understand your options.

Step 5: Wait for the insurance company’s decision

After filing your internal appeal, you’ll need to wait for the insurance company’s decision. The review process can take some time, and the insurance company will assign employees who weren’t involved in the initial denial to re – evaluate your claim. Be patient during this period, but also keep track of the time elapsed. If the process is taking longer than expected, follow up with the insurance company to inquire about the status.
Pro Tip: Keep a log of all your interactions with the insurance company during the waiting period, including the dates, times, names of representatives you spoke with, and the information discussed.
As recommended by industry experts, it’s important to stay proactive throughout the internal appeal process. Try using a claim tracker spreadsheet to keep track of all the steps and deadlines involved.
Key Takeaways:

• Always check the time limit for filing an internal appeal and set reminders.
• Gather and submit comprehensive documentation when filing the appeal.
• In urgent situations, understand your special rights and options.
• Be patient during the review process but follow up if it’s taking too long.

External Review Process

Did you know that as many as two – thirds of rejected health insurance claims are recoverable? An external review can be a crucial step in getting your denied claim approved. Let’s explore the external review process for health insurance claims.

Eligibility and General Considerations

Health insurance claims denials can be a significant financial burden for policyholders. If your insurance company refuses to pay the claim, you have the right to file an appeal, which includes an external review from an independent entity. The HHS – Administered Federal External Review Process applies to “adverse benefit determinations,” including those that involve medical judgment and rescissions of coverage.
If your state doesn’t have an external review process that meets the minimum consumer protection standards, the federal government’s Department of Health and Human Services (HHS) will oversee an external review process for health insurance companies in your state. As recommended by industry experts, it’s important to understand if your situation is eligible for external review as soon as you receive the claim denial notice.

Requesting an External Review

For health plans or issuers that participate in the HHS – administered federal external review process

If your health plan or issuer participates in the HHS – administered federal external review process, here are the steps:

• Find an external review request form at http://www.externalappeal.com/Forms.
• Call Toll Free: 888 – 866 – 6205 to request an external review request form
• Fax an external review request to: 1 – 888 – 866 – 6190
• OR Mail an external review request form to: MAXIMUS Federal Services 3750 Monroe Avenue, Suite 705 Pittsford, NY 14534
• OR Access the Electronic Portal at www.externalappeal.com (In the future, you will be able to request an external review online at http://www.externalappeal.com/RequestReviewOnline.
  A practical example: Sarah had her claim denied by her insurer. Since her health plan participated in the HHS – administered federal external review process, she called the toll – free number, got the form, and submitted it. She was then able to move forward with the external review.
  Pro Tip: Keep copies of all documents related to your external review request, including the form, any correspondence, and proof of submission.

For health plans that do not participate in the HHS – Administered federal external review process

If your health plan does not participate in the HHS – Administered federal external review process, the health plan will tell you how to request external review. It’s essential to follow their instructions carefully to ensure your request is valid.

Outcome

An external review either upholds or overturns your insurer’s decision to deny payment. Your insurer is required by law to accept the external reviewer’s final decision. A data – backed claim: A 2020 study estimated that the automated processing of claims saves U.S. insurers more than $11 billion annually. This shows the importance of an efficient review process.
If the external review decides in your favor, you will receive the claim payment. However, if it upholds the insurer’s decision, you may want to consider further legal action, although you must first complete and exhaust your health insurance plan’s claim processes before filing an action in court.
Try our claim appeal status checker to stay updated on the progress of your external review.
Key Takeaways:

• The external review process can be a powerful tool in appealing a health insurance claim denial.
• Eligibility for external review depends on state regulations and the nature of the claim denial.
• Follow the specific steps for requesting an external review based on whether your health plan participates in the HHS – administered federal process.
• The outcome of the external review is legally binding on the insurer.

FAQ

How to start the health insurance claim appeal process?

The CDC recommends starting by understanding the denial reason. First, check the time limit set by your insurer, often around 90 days. Then, notify the company of your appeal intent, usually via letter or online form. Gather documents like policy details and medical records. Detailed in our Internal Appeal Process analysis, this structured approach is key.

Steps for gathering supporting documentation for a claim appeal

Clinical trials suggest comprehensive documentation strengthens your appeal. Get doctor’s notes, policy documents, denial letters, and medical records from providers. If there were coding errors, obtain an updated bill. Organize these in a logical way. Our Supporting Documentation for Claim Appeal section has more details.

What is the external review process for health insurance claims?

The external review involves an independent entity re – evaluating a denied claim. Eligibility depends on state regulations and claim nature. If your plan participates in the HHS – administered federal process, follow specific steps to request the review. The outcome is legally binding on the insurer.

Internal appeal vs external review: What’s the difference?

Unlike an internal appeal, which is filed with the insurance company and reviewed by its employees, an external review is conducted by an independent third – party. The internal process has specific company – defined steps, while external review options depend on plan participation in federal or state processes. Professional tools can aid in both.