Did you know that more than 81% of appealed insurance denials are overturned or partially reversed? Despite this, only 12% of patients actually filed an appeal on their prior authorization denial. If you or a loved one ever receives a denial for a medication, treatment, or procedure, knowing how to respond can make a significant difference! This article outlines the essentials of health insurance appeals and how to advocate for the care your doctor recommends.
What to Do If Your Claim Is Denied
Firstly, contact your health care provider, as they may have submitted paperwork with the wrong billing code. Your health care provider will likely submit the appeal on your behalf, since they can best provide additional information for why the treatment, procedure, or equipment is needed.
Then, if that doesn’t work, carefully follow the steps outlined in the “Evidence of Coverage” document available from your Medicare Advantage plan. It is very important that you create a document log listing all of the communications (phone calls, emails, written) you receive or initiate (individual’s name, title, role, company, content, etc.).
One of the most important parts of the appeals process is keeping clear documentation.
Keeping Records During Your Appeal
Document a running log of phone calls, emails, and written correspondence sent via U.S. Mail. This information is needed if you appeal denials of drugs and/or procedures, as well as a payment decision. You can also request a peer-to-peer review of denials from your healthcare provider, so keep a log of those calls, as well. It will also be helpful if you receive poor customer service and need to talk with a Plan Administrator. Keep your log simple. Track the following information for every phone call to your insurance company, health services provider(s), pharmacies or durable equipment retailers. Here is a sample guide:
- Date & time
- Name of person answering your call
- Your question(s) and their response to your question(s)
- If transferred, time of transfer, name of person to whom you are transferred, their title, department and direct phone number. Include their response to any different/additional question(s).
- Time call ended. If necessary, add further notes about the call—person(s) politeness, if confused by question(s) vs knew answer right away, if you were transferred to the correct person, etc.
For emails and correspondence:
- Log all written correspondence in order by date, including sender’s name, title, organization, subject and deadlines for required action.
- Hard copy or online folder to store all emails.
- Hard copy of the correspondence received or scan it into your online folder. Note the date you received it on the document.
Don’t Give Up After a Denial
A simple step-by-step guide to starting your appeal
When your doctor says you need a particular medication or treatment, your insurance company may tell you they won’t pay for it. We believe YOU SHOULD NEVER TAKE NO FOR AN ANSWER, at least not without a fight.
Be one of those who do! Here is how:
1) Call your doctor’s office as soon as you receive a denial notice. Often, they can file an appeal for you. For example, many denials are due to the doctor’s office miscoding their claim, or they sent insufficient information.
2) Keep a detailed record of all communications during your appeal process, noting dates, names of representatives, specific reasons provided for the denial, and other information discussed.
3) If your doctor’s office can’t help you, contact your insurance company. Ask for a detailed explanation of why your claim was denied and for them to also send you the explanation in writing.
4) If the reasons for denial seem unjust or unclear, ask the insurance company to send you detailed instructions and forms on the appeal process. The information is also available on their website.
5) If you versus your doctor’s office must file the appeal, follow instructions carefully, and give clear and detailed answers. You should describe the service or treatment you need and the specific reasons for the claim denial. You can also call the Washington State Office of the Insurance Commissioner for advice and assistance at 800-562-6900.
Additional Resources
This may feel like a lot of information, and at times the appeals process can seem overwhelming. However, understanding these steps can help ensure your healthcare needs are properly reviewed and can give you greater confidence when advocating for the care your doctor recommends.
If you would like to learn more about the appeals process, the following trusted resources provide additional guidance:
• Fighting a Health Insurance Denial? Here Are 7 Tips To Help – A helpful article from the Kaiser Family Foundation outlining practical steps you can take after receiving a denial.
• How To File A Medicare Appeal – Another Kaiser Family Foundation guide explaining the Medicare appeals process and what to expect.
• Medicare Appeals 101 –An educational webinar hosted by the Center for Medicare Advocacy. View slide presentation here. Note: This video is an advanced, technical presentation. (Webinar/April 2025)