How to Appeal When Your Medical Insurance Declines Your Claim


 How to Appeal When Your Medical Insurance Declines Your Claim

If you're like most people, you've had your frustrating moments with insurance companies. And if you've ever seriously considered cutting down on the layers of bureaucracy that often stand between you and your health treatment, read on!

Medical expenses can be overwhelming, even for those earning a high salary. Sometimes it feels like the only way to get the help needed is to go through long appeals processes that require submitting receipts and waiting weeks for updates from denied claims. These are just some of the many ways insurance companies can treat patients unfairly — but what do you do when they turn them down? Here are 9 proven strategies for appealing a denial.

1. Ask for an Exception

If you've submitted all the necessary information and tried to follow the company's request for additional information, it may be time to consider requesting an exception. They sometimes accommodate by creating a small group of approved providers that will still accept your insurance instead of listing you as a denied patient and sending your claim to collections. There are other ways that this can work out – maybe even with a special discount on your prescription drugs – so be sure to ask your insurer about exceptions before you file a formal appeal.

2. Contact the Health Maintenance Organization (HMO)

Maybe your HMO hasn't properly received your request, so they're denying you coverage. If that's the case, call them and ask for the reason. They may be able to provide you with a reasonable explanation for their decision if it's something they've received from another source. With an HMO, you can also request that your upcoming surgery be included in your benefits package. Also consider asking about why there are no lower deductibles or co-pays for routine procedures (like checkups). Although this can be costly and frustrating to many patients, you may have some luck with an exception request if it results in more comprehensive coverage on a new plan from the HMO.

3. Amend Your Claim

If you have existing coverage with your insurer, but something was missed from the original claim or you've been accidentally double paying for similar services, ask them for an amendment to be entered on your account. This will allow the insurance company to review your claim again and decide if it should cover a procedure that applied for prior to the original denial. If you were expecting a reimbursement or payment from them, don't give up hope – this may just be the solution needed!

4. Contact the Insurance Company Directly

If the insurance company has failed to update their records, contact them directly (or their parent company if it's a large corporation). A simple call can clear up a lot of confusion and prevent you from having to use formal appeal methods later. At the very least, you'll learn more about why your claim was denied when talking directly with the insurance provider.

5. Get Legal Help

In some cases, denial may be due to an honest mistake on your account that wasn't identified at the time of filing. Even though it's difficult to make a mistake with health insurance, it's always possible. If you think there is enough evidence that your claim was denied incorrectly, you should consider working with a lawyer to file an appeal. The cost of hiring a lawyer can be daunting to many patients – but the strategy mentioned in the article may not work if you can't get in touch with your insurer directly.

6. Get a Reimbursable Provider

If you cannot get through to the insurance company on your own, follow up with an email or call of your own and remind them that this is an option for those that need it. They won't always do it, but they often have a list of verified provider that offers a discount to members. If you are out of work or have a small budget for health care, then this is an excellent option that will help pay off the rest of your medical bills.

7. Tell Your Story to the Media

If you've been getting denied from your insurance company for a long period of time or if you have worked hard to create change within the company's standards, then it may be worth writing a letter to the editor about current problems being faced in today's healthcare system. Sometimes, a first-hand experience can help others to reconsider their opinions about health insurance. If you're passionate about the subject, others will notice and it may just help you get the coverage that you need.

8. Get Help from Non-Profits & Charities

If your local community doesn't have many resources to help cover medical expenses, take advantage of non-profit organizations if they exist in your area. Some charitable groups will be willing to help pay for medical bills if you can prove that you are financially handicapped. This is a great option for those who had a job at one time that provided insurance, but it was recently lost. Just make sure that this option is available in your area before you begin to rely on it.

9. Wait & Sue

If all else fails, consider waiting until after the required appeal process is over before taking action against the insurance provider. If you need medical care and you've been denied, there are other ways to get help if you can wait a little longer. The biggest risk in this case is that your illness may worsen while waiting for resolution – but sometimes the risks outweigh the consequences of not getting treatment soon enough. If you decide to wait until the next step, then you should also consider taking legal action against the insurance company. If they've been knowingly denying your claim while you are in need of medical attention, then it's time to take action and fight back.

You can not afford denial! If you have been denied coverage, don't give up – get help from someone who knows what they're doing. It's worth the initial consultation to find out if there are other ways for you to get relief from the stress of fighting an insurance company!

Need additional help? Check out our article on how to appeal a denial with Blue Cross Blue Shield. Visit our website today for information about our services and how we can help you gain the coverage you need without suffering from denial!

The HealthcareAccess™ Difference

HealthCareAccess™ uses a proprietary algorithm to analyze your claim, dental records, and outpatient office visits to provide a detailed analysis of your health insurance. It's the only tool out there that can help you understand your options based on what other providers are being paid for the same procedure in addition to analyzing whether or not coverage has been denied due to a pre-existing condition. The HealthcareAccess™ system also provides action items that will support you throughout the process of dealing with denial so you don't have to do it alone.


It's not easy to deal with denials from the health insurance companies, but they are a necessary evil. The most important thing you can do is look for an outside source that can help guide you through the appeals process. Trying to do it on your own takes too much time and puts too much stress on yourself when there are plenty of resources out there to help you get back on track. If you feel like this situation has made your life unmanageable, contact us today for free consultation and we'll get started right away!

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