What to Do When Your Denied Claim Appeal is Rejected
Making an insurance claim doesn’t guarantee coverage, in fact, providers will often reject claims for a number of reasons. The first response for the insured is usually to appeal the rejection, but your provider can continue to deny your claim, even after an appeal. Keep reading to learn what the next steps are when your denied insurance claim appeal is rejected.
Appealing a Denied Insurance Claim
When you try to get a medical treatment pre-authorized or make a claim for reimbursement, the insurance provider can either accept or deny it. If denied, the insured usually has the option to appeal it by providing more evidence that the treatment is needed — but what happens if the appeal is rejected?
Why a Denied Claim Appeal is Rejected
Your documentation is incorrect or incomplete. You may be missing essential forms, bills, and medical records.
Your explanation and evidence to support it is lacking, meaning your provider doesn’t believe the treatment is medically-necessary in your case.
The treatment is excluded from your policy or you have already met your coverage limit for the year.
You missed the deadline to file the appeal.
Your insurance provider should provide an explanation as to why the appeal was rejected.
What to Do When Your Denied Claim Appeal is Rejected
Review the Denial Letter Carefully
The first step in addressing a denied claim appeal is to read the denial letter thoroughly. Pay particular attention to the reason for rejection. Look for any details provided on the specific grounds for denial; are they reiterating the previously cited reasons, or is there new information that needs addressing?
Compare with Your Original Claim and Appeal
Now that you understand why your appeal was denied, reference your original claim and the appeal you submitted. Were there specific details or documents that you assumed were included but were not? Look for discrepancies in dates, treatment descriptions, or provider signatures. If your documentation is incomplete, start gathering the necessary evidence.
Contact the Insurer for Clarification
Contact your insurer for more information and advice if needed, especially if you’re having trouble understanding the denial letter. When you contact the insurer, request a clear and comprehensive explanation regarding your appeal’s rejection. Ask about what you can do to strengthen your case and whether there are specific forms, documentation, or evidence they need.
Gather Additional Evidence
If you believe that there are grounds for a second appeal, it’s important to gather additional evidence and documentation. Talk to your doctor about the denial and ask for their assistance in providing more supporting documentation.
File a Second Appeal
Most insurance providers will allow you to submit a second appeal. In your appeal letter, reference the reasons for denial, outline new evidence or documentation, and articulate why you believe the treatment should be covered. Be sure to include all the updated and additional documentation you’ve gathered.
If Your Second Appeal is Denied
If your second appeal is also denied, you still have options:
Some insurance policies offer an independent review process from a third-party. Research whether your insurance company has this option and take advantage of it if available.
If you’ve exhausted all options and still face denial, consulting with a lawyer who specializes in insurance law may be needed. They can help you understand your rights and possible legal actions you can take.
Seek out a new insurance policy that can better fulfill your needs to prevent unnecessary appeals in the future. We can help you find one!