Evidence You Need to Appeal a Health Insurance Claim Denial

September 30, 2024

Understanding Health Insurance Claim Denials

Nobody ever expects to receive a denial notice from their health insurance company; yet every day individuals in Oklahoma and throughout the country find out that their claims were rejected. These notifications are more than surprising — for many they are devastating. Medical care is costly, and most individuals are not in the position to pay out of pocket for the treatment they need. In some cases, these denials are made in response to a request for pre-authorization for necessary medical treatment.

While denials are commonplace, not everyone who receives one realizes that they have the right to appeal. That said, the appeals process is intentionally complex. Navigating it successfully requires gathering a great deal of evidence. In many cases, engaging a seasoned healthcare denials attorney can be a valuable decision.

Necessary Evidence

The first step in appealing the decision of your health insurance company is to have all of your documentation in place.

Gathering this evidence may take a bit of effort; but dedicating the time to ensure you have everything you need is an important investment.

It could mean the difference between a successful appeal and one that is rejected.  Consider some of the documentation you should have on hand:

Medical Records

You want to have a complete set of your medical records that are relevant to the denial. In some cases, you may need to go back to your physician to make sure the information you have is complete and up to date. Request that your doctor include their notes from your visits, important historical information, and your diagnosis.  Additionally, request copies of all lab results and tests performed, as well as details on any prior treatment received.

Explanation of Benefits (EOB)

As part of the denial documentation you received from your health insurance company, there should be an Explanation of Benefits (EOB). This paperwork is provided to policyholders after they have received care. It contains valuable details including the total amount you were charged, the complete list of services provided to you, the amount your provider charged, the percentage your insurer will pay, and the amount you owe.  This final number is the cost of the medical treatment, less deductibles and copayments as well as co-insurance and negotiated rates/discounts with specific providers.

Independent Medical Opinions

Not everyone looking to appeal their health insurance company’s decision will have documented independent medical opinions, but many will. These include second opinions you may have sought with regard to your health problem. If you have already begun the appeal process, you may have gone through some type of dispute resolution and had your case reviewed by an independent provider.  Their report also falls under this umbrella.

Relevant Policies and Guidelines

Whether your insurance company’s response to your claim was justified depends upon the terms of the policy you purchased.  In order to gain a complete understanding of exactly what is covered and what you may be entitled to receive, you would want to have a copy of your policy. This would allow you to understand all included situations and anything that would disqualify coverages.

Additional Tips for Gathering Evidence

Other Relevant Information

The list above is not all of the information you should collect. Also consider gathering the following documents:

• Copies of any correspondence with your insurance company, including hard copy mail, emailing, and notes you took while speaking with insurance representatives
• A copy of the denial letter your insurance company sent to you
• Any documentation you completed and submitted regarding pre-authorization or medical records releases
• Medical professional studies that support the treatment you need. (These may be particularly helpful if your insurance company is claiming the requested treatment is experimental.)

While this may seem like a lot to have on hand, you never know what you will need to support your appeal.  Having all documents at your fingertips when you meet with your health insurance denial attorney can help them review your case more quickly and determine how they can best help you.

The Appeal Process

Appealing a health care denial is complicated and managing it from beginning to end is time consuming.  Understanding the process, at the outset, is valuable. If you know what is involved, you can make sure you are prepared.

• Ascertain why your claim was denied:  Conduct a thorough review of the denial letter.  In some cases – for instance, if there was missing information — the fix can be as easy as resubmitting the claim.  In other instances, the process will be more challenging.
• Read and review your health insurance policy: Once you determine the reason for the denial, you should look at your policy to understand your level of coverage.
• Gather documentation: If you are going to move forward with an appeal, you would want to gather the broad range of documentation discussed above.  Having this handy is valuable and saves time and aggravation as you move forward.
• Draft and submit an appeal letter: Make sure your letter includes all important information, including your name, date of birth, and policy number.  You want to clearly state why you are appealing and refer to relevant documentation that you will attach. It is crucial that you submit your appeal package in accordance with the requirements of your insurance company.  Some may accept only electronic appeals; some may want documents to be faxed; and still others may require a hard copy to be mailed to them.  If you mail your appeal, consider sending it certified or overnight, so you have proof of receipt.
• Escalate Your Appeal: If your appeal is denied, you may want to escalate and request an external review.  In some cases, you may want to move forward with legal action.

Managing the appeal process can be overwhelming.  Consider working with an experienced and knowledgeable healthcare denials attorney.

Doug Terry Can Help You Manage Your Appeal, Including Gathering Appropriate Evidence

Reach Out to Doug Terry Law Today

If your health insurance claim was delayed, denied, or underpaid, filing an appeal is your right.  That said, you may find the process to be mind-boggling.  The amount of paperwork and communication required is astounding.  For this reason, many opt to engage professional legal representation.

In Oklahoma, many turn to Doug Terry, the founder of Doug Terry Law, for help with their insurance appeals.  He knows how to gather appropriate evidence, draft correspondence, respond to insurance company inquiries, and negotiate settlements. In those cases where an agreement between his clients and their insurance company cannot be reached, he aggressively litigates on their behalf.

Your insurance company is required by law to act in good faith when it evaluates your health insurance claims. When they don’t, taking action is in your best interests.

You don’t want to bear the financial responsibility for your treatment; the costs can have a life-changing impact on your financial security.

Mr. Terry leverages his past experience as an attorney for insurance companies as he represents his clients today. He appreciates the value of time and is ready to meet with you immediately.  Reach out to him and his team today at 405-463-6362 to schedule a free consultation.