Nurse care manager Lenzy Mixon got a call from a member about a large bill he received for a stay at a skilled nursing facility.

He checked with his doctor, who assured him the stay had been pre-approved by his health plan. His next call was to us. Mixon said she was sure it was a mistake, so she reached out to a utilization review nurse and a customer advocate. Together, they found the error that caused the claim to be denied, adjusted the records and sent it through again for payment. “He was relieved and happy hearing that the claim was being adjusted so quickly,” Mixon said. 

While not every claim denial is so easily fixed, there are times a claim doesn’t get approved for reasons other than the service not being covered by a member’s health plan.

Do you know what to do if a claim isn’t approved?

First, Ask Why

If you have a claim that isn’t approved, you can look at the explanation of benefits (EOB) for the claim to find out why. An EOB is generated for your medical claims to help you track what your insurance is covering and what amount you may need to pay, such as a copay or coinsurance.

If a claim is denied, the EOB will explain the reason for the denial.

Find Out Your Next Steps

Do they have the wrong birth date listed for you? Is the address your doctor listed different from what we have on file? If the claim wasn’t approved because of an information error, reversing the denial may be fairly quick and easy.

Call customer service at the number on your member ID card. You can give the customer advocate the right information to correct your file. If your provider’s office made the mistake, you can call the billing office to get the information corrected.

If the service isn’t preauthorized or is denied for payment for another reason, you may need to ask that the claim be reviewed. This is called appealing the decision. You can appeal by phone or by mail. You, your doctor or another person you’ve named to represent you can appeal.

Understand the Appeals Process

There is a multi-step process in place that can help you if you think a claim has been denied in error. It is outlined in an insert included with your EOB. It is also explained in your benefit information.

If our reviewer is going to deny a service as not medically necessary, your doctor will receive a notification. That notification will include the option to schedule a call with the reviewer. Your doctor can review the case over the phone with us to try to resolve the issue.

If the issue is not resolved and the claim is denied, you can appeal. A standard appeal is an internal review of your claim. You’ll call or send a letter to ask that the claim be reviewed to see if something can be done to reverse the denial. If a claim is denied for a medical reason, a medical doctor will review the claim.

If a standard appeal does not resolve the issue, you can request to have a second medical reviewer look at the request. This second level of appeal is done by an outside, independent review organization. Your EOB will explain what types of denials can be sent for external review. There is no cost to you for an external review. 

Get Started

You’ll need to provide as much information as you can to support the claim. Maybe the claim reviewer didn’t have the films from your MRI that showed you needed the surgery your doctor requested. It may be that a referral was required, and the referral wasn’t documented. The need for more information is another reason that often leads to a claim not getting approved.

Medical review will require more information. For example, you may need:

• A letter from your doctor explaining why the requested treatment should be approved
• Patient notes from your treating physician on other care you have had for your condition
• The results of other tests or procedures related to the request
• Current medical articles or study results that support the treatment’s effectiveness
• Your own letter explaining why you believe the treatment is needed

Hang in There

For things like wrong information, a quick correction can be made and the claim refiled for approval.

But other reviews take time. A standard appeal takes about 30 days for review for getting care pre-approved. Other appeals may take up to 60 days.

If your life or health could be at risk by waiting, you can ask for an urgent appeal. If you qualify, the review will be handled within 72 hours. You and your doctor will get a phone call from us explaining the decision and next steps.

These timeframes start when you file the appeal, not from the time of your treatment or from when the claim wasn’t approved. You have 180 days to file an appeal from the date the claim wasn’t approved.

An external review takes about 45 days. If you qualify for urgent review, the outside review organization will give you a decision within 72 hours. You have four months from the date of your internal review decision notice to file a request for external review.

Sources: Engaging with Insurers: Appealing a Denial,  Patient Advocate Foundation

Originally published 7/1/2020; Revised 2021, 2023, 2024