Medical claims can be denied for any number of reasons:
- Your insurer does not have enough information to process your claim
- You've reached your lifetime maximum limit with your insurance provider, so they can no longer pay for your claims
- You've received services not covered under your plan
- You've received experimental medical treatment
- You have a pre-existing condition that prevents you from being covered for certain services
- The provider put the wrong code for the service on your claim
After you've determined the insurance provider's reasons for denying your claim, do your research to make the most solid appeal you can. This means talking to your doctor to better understand your illness or injury, getting copies of letters between your doctor and insurance provider, examining the coverage of your insurance policy, and finding out how to appeal a claim denial under your specific plan. (There might be different appeals processes based on the type of dispute you have). Call your insurance company to find out more about your claim denial so that you can better address their concerns in your resubmitted claim. Sometimes all that is needed is more information about the services you received, and your resubmitted claim can be accepted.
To appeal your claim, send an Insurance Claim Denial Information letter to provide additional information and request that your claim be reconsidered.
If your insurance company continues to deny your claim and not cover your medical expenses, and you think they are wrong, you can contact your state insurance department or Find a Lawyer.
This article contains general legal information and does not contain legal advice. Rocket Lawyer is not a law firm or a substitute for an attorney or law firm. The law is complex and changes often. For legal advice, please ask a lawyer.