My Private Health Insurance Plan Won't Pay for Health Care I Need. What Can I Do?
I Want To Appeal My Insurance Plan's Decision. What Can I Do?
Common Reasons Health Insurance Won't Pay
How Long Do I Have to Appeal? What Are Appeal Deadlines?
I Know My Appeal Deadline and I have a Written Denial. How Do I Prepare My Appeal?
My Insurance Company Denied My Appeal. What Can I Do?

My Private Health Insurance Plan Won’t Pay for Health Care I Need. What Can I Do?
You can appeal their decision not to pay for your health care. Write a letter to your insurance company telling them why they were wrong to deny you health care.

I Want to Appeal My Insurance Plan’s Decision. What Can I Do?
Appealing your insurance plan’s decision can take several steps. We explain each step on this page. You need a written denial. A written denial is a letter from your health insurance plan saying they won’t cover the health service you need. A written denial also must say why they won’t cover your service. It also explains your right to appeal. Do you have a written denial? If not, contact your insurance plan. Ask them for a written denial.

Common Reasons Health Insurance Plans Won’t Pay.

- Your plan says the health care service or item you want covered is not medically necessary

- You did not get a prior authorization before you got the health care service or item, and your plan says you needed one.

- You want to use an out of network doctor or other provider

        - You did not get a referral from your doctor

- Your plan says the health care service or item is not a covered by your plan.

We explain these reasons more here. Next we explain what you need to do to appeal your health care denial.

How Long Do I Have to Appeal? What Are Appeal Deadlines?
Read the written denial your health insurance company sent. Find the date that your health plan denied your health care coverage. Your written denial will also say how many days you have to appeal from that date. The number of days is different with every insurance plan. Be careful with appeal dates. The insurance plan doesn’t have to consider your appeal if you miss the appeal deadline.

I Know My Appeal Deadline and I Have a Written Denial. How Do I Prepare My Appeal?

You can appeal the decision by writing a letter or by calling your insurance company. Say why you think your insurance company was wrong to deny your health care. Say why you think the health care item or service should be covered. Ask your doctor or care provider to write a letter that explains why you need the health care. Ask your doctors to also discuss other treatments you have tried and why they haven’t worked. Some of the best arguments are simple and use common sense. You can call the Office of Health Care Ombudsman at 1-800-917-7787 for help.

Here’s an example:

John Doe has chronic back pain. His doctor prescribed surgery. John’s insurance company denied coverage for the surgery. The company says it won’t pay for surgery for his condition because it is not medically necessary. John can appeal this decision. In a letter to the company asking for a First Level Appeal, John should tell the company why it should pay for the surgery. In this example, John needs to show that the surgery is medically necessary. He will probably need help from his doctor or health care provider to do this. The provider can write a letter to the company and provide written records that show why the surgery is medically necessary for John.

My Insurance Company Denied My Appeal. What Can I Do?
You can appeal again. There are different levels of appeal. If you lose at the first level appeal, you can appeal up to the next level. Do you want help? Call the Office of Health Care Ombudsman at 1-800-917-7787.

The next level appeal is usually the Second Level Appeal. The notice of decision denying your First Level Appeal should give you a new appeal deadline. Be sure to get your appeal request in before the deadline. A Second Level Appeal can be done by telephone call or by another letter to the insurance company. Do you want a conference call? Ask the insurance company to set it up. Ask your doctor or health care provider to participate with you on the call.

Did your insurance plan deny your Second Level Appeal? You may be able to ask for an External Appeal. In an External Appeal, a person who doesn’t work for your insurance plan makes the decision. External Appeals are usually done by telephone conference call.