You have options if your health insurer says no to a treatment or a bill dispute. This short video explains your right to appeal the decision.
Your appeal rights when your health insurance company says no
You can win an appeal, but it takes some work. First, read the denial letter. Why was coverage denied? What's the appeals process and timeline?
If it's a billing or claims-processing error, call your medical provider's billing office and ask them to clear things up with the insurer.
If it isn't a billing or claims-processing error, you'll need to appeal to overturn it.
Your health insurer must allow continued care during an appeal
Your health insurer can't change, reduce or stop benefits for an ongoing course of treatment without providing you advance notice and an opportunity for review.
Please note, that if you lose your appeal, you may have to cover the medical costs for your continued treatment.
What can you do about outstanding bills during the appeals process?
Talk with your medical provider's office to let them know you plan to appeal the denial. Work with them to handle any outstanding bills.
If a bill is due, you can:
- Delay paying it until you know the outcome of your appeal. Ask your medical provider's office to not send the bill to collections, which they may or may not agree to do.
- Set up a payment plan and try to negotiate the amount you owe (to avoid having the bill sent to collections).
- Pay the bill and get reimbursed by your health plan if you win your appeal.
- If your health plan won't pay, try to negotiate a lower price.
You have to decide what's best for your situation.
Tips for filing your appeal
These tips can help the appeal process go smoother for you:
- Identify your type of insurance coverage and find out if you have a group, individual or government-sponsored plan, and which law your plan follows.
- For Medicare and other plans like TRICARE, Apple Health for Kids, etc. you will need to follow their appeals processes.
- Find out the deadline for an appeal. Where do you send it? These are usually in the denial letter. If not, ask your insurer.
- Keep a log of every call, email and letter. Here's a printable example of a contact log( PDF, 641.36 KB).
- Gather your medical records. If you don't have them, ask your medical provider for copies. Here's an example letter (Word, 32KB).
- Appeal letters should be to the point, timely and specific about the outcome you seek. Here's an example appeal letter (Word, 24KB) and a list of common reasons for a denial and example appeal letters you can use.
- It helps to have a supporting letter from your medical provider. Give them a copy of the reason for denial.
- Keep the originals of your documents. If you have to mail documents, make copies and send them as certified mail.
If you lose an appeal, you can ask for an external review
If you lose your appeal and your health plan upholds the denial, you can request an external review. This option should be outlined in the determination letters you receive from your insurer. You can also contact your health plan's customer service line to get more information about asking for an external review.
External reviews are performed by an independent review organization (IRO). An IRO isn’t affiliated with your insurance company and doesn’t have a financial interest in the outcome of your case. The IRO can either uphold or overturn the insurance company's position. Once an IRO reviews an appeal, its decision is binding. All IROs in Washington state must register with and be certified by the Office of the Insurance Commissioner.
Our IRO search tool allows you to search IRO decisions. You can find cases involving your insurance company, diagnosis, treatment, outcome or reason for the appeal.
You may want to also file a complaint
The appeals and complaint processes are different. They can take place simultaneously without affecting each other. If in doubt, you may want to try both avenues to resolve your issue.