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Tips on Appealing a Claim Denial

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After you have identified and researched the reason your health plan denied your claim or medical service try to resolve the situation over the phone.  Contact your health plan through their customer service line and ask them to explain and reprocess the claim.  If it can not be resolved over the phone, your health plan is going to require you to submit your appeal in writing. 

Tips on Appealing:

1. Identify the address where you will need to mail your letter of appeal.  The appeals address may be different than the address the claim was originally submitted.

2. Prepare to send your appeal letter via certified mail with return receipt requested.  Many times a health plan’s mail room is not the most organized and efficient place and your letter could get lost, mislabeled or thrown out.  If your health plan does not receive the letter or loses it, how will you be able to prove that you actually mailed your appeal in time without a return receipt?

3. When writing your appeal letter, indicate the date, claim number, date of service, your member identification (subscriber) number, group or policy number, amount of charge, medical provider name and then describe the denial, why you are writing, and what you are requesting.  (Appeal letters must be clear and concise.  If you need assistance in wording your appeal letter, please visit our Appeal Letter Order Form to purchase an appeal letter for under $10.00.   To view a sample appeal letter, click here.

4. Include with your appeal letter any supporting documentation, such as letters of medical necessity from your physician, medical records, progress notes, radiology or pathology reports, etc.  

Final Words:

There are common denominators in appealing to a health plan.  From reviewing your policy booklet, documenting your conversations and actions, being persistent but friendly and developing a good strategy and approach would go a long way in having a favorable outcome.  Please know that there could be multiple methods of appealing a single problem or situation, but we hope we have provided a basis of understanding that appeals could be won with a little bit of effort, proof of medical necessity, research, persistence and possibly, luck.  

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Health Symphony provides general information and does not guarantee, express or implied, to the results obtained from its use.