Health Insurance: How To Handle a Claim Dispute

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Perhaps you thought the medical treatment you recently received was covered by your health insurance and didn’t give it a second thought. A few weeks later, however, you receive a letter from your insurance company stating your claim was denied

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Take a deep breath. If your health insurance provider refuses to pay your claim, you have the right to file a dispute. However, before you get to the actual filing process, there are a couple of steps you should take.

Review the Denial Letter and Your Health Insurance Policy

The first thing to do is review the denial letter to find out the exact reason for the denial. Then review your health insurance policy for what is covered and also any limitations and exclusions.

Contact Your Health Insurance Company for Further Information

After reviewing your policy and the denial letter, if you still think your claim shouldn’t have been denied, contact your insurance company and ask for clarification. Perhaps your insurer needs additional information or there was an error in billing. If that’s the case, take the steps to resolve the issue and resubmit your claim. 

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If the reason for the denial is not something you can easily resolve, ask the representative how to appeal the decision. 

File an Appeal If Needed

Legally, you have the right to file an appeal if your health insurance company denies your claim. Follow the steps to make an appeal, and note whether there is a deadline for making the appeal.

You also should contact your doctor or the hospital who provided the services that are related to the appeal. Let them know that you have filed an appeal and request that they hold off on billing you until a final decision is made. You also might need to ask your doctor to write a letter to the insurance company explaining why the medical treatment you received was necessary. 

Wait for the Results of the Internal Review

Once you’ve filed the appeal, also known as an internal review, wait until the insurance company contacts you by phone or mail about its decision. Representatives from the company who were not involved in initial claim denial will review your appeal to see whether it can be overturned.

Request an External Review If the Outcome Isn’t Satisfactory

The next step is to file for an external review. According to HealthCare.gov, you have four months from the final notice that your claim has been denied to file an external appeal. During an external appeal, your health insurance company no longer has input and a third party will review your appeal. Whatever the external review decides is final, and your insurance company has to accept its decision.

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About the Author

Cynthia Measom is a personal finance writer and editor with over 15 years of collective experience. Her articles have been featured in MSN, AOL, Yahoo Finance, INSIDER, Houston Chronicle and The Seattle Times. She attended the University of Texas at Austin and earned a Bachelor of Arts degree in English.
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