Why Do Claims Get Denied?

Health insurance claims get denied for a myriad of reasons. In some cases, denials result from clerical errors. Maybe your health care provider’s billing staff entered an incorrect code, or maybe the claim was accidentally sent to the wrong health insurance company. Other times, the issue may be related to your coverage limits.

You Have a Right to Appeal Denied Health Insurance Claims

If your health insurance company refuses to cover a claim, you have the right to appeal the decision and have it reviewed by a third party. Your policy should outline how to appeal a denial. In general, there are two levels of an appeal, including an internal appeal and a third-party external review.

Internal Appeal

Your first step for resolving a denied claim is to call your health insurance company and ask that it conducts a full review of the decision.

First, you need to complete all forms required by your health insurance company or send a letter to an insurer explaining the reason for your appeal. You must include your name, health insurance ID number and claim number in this letter. Then, submit any relevant additional information, such as a letter from your doctor explaining why the service is necessary. If you need help filing the appeal, the Consumer Assistance Program in your state can file on your behalf. If you have an agent/broker they can assist you at no cost to you.

You have 180 days from the time your claim was denied to file an internal appeal. If your health situation is urgent, or if the health insurance company stands by its original decision, you can simultaneously file an external review.

External Review

To have your denial handled by a third party, you can file an external review. You must begin this process within four months of the date you receive the final determination from your health insurer that the claim has been denied. Someone else, such as a doctor or health insurance agent, can file an external review on your behalf.

This process may be the best option if your claim was denied because the health insurance company did not believe the service was medically necessary and your doctor disagrees. You may also request an external review if your health insurance canceled your policy because it claims that you provided incorrect information when you first enrolled.

In Nevada, as in all states, health insurance companies are legally required to accept the outcome of the external review.

Nevada Insurance Enrollment Helps You Navigate the Appeals Process

The appeals process can be frustrating, but at Nevada Insurance Enrollment, our health insurance agents can help. We can review why your health insurance claim was denied and help you through the next steps.

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