December 3, 2024
Knowing how to appeal a health insurance claim denial is essential. Accepting your insurance company’s decision as final leaves you responsible for the cost of your treatment. In Oklahoma policyholders have the right to both an internal appeal and an external review if the insurer’s decision is not in their favor. If your claim has been denied, navigating the appeals process can be overwhelming. Engaging the assistance of a seasoned health insurance claims denial attorney can be valuable.
Fighting a Health Insurance Claim Denial
Has your health insurance claim been denied? If so, you should contact an Oklahoma insurance claim lawyer experienced in the appeals process. Engaging the knowledge and experience of an attorney can be the difference between success and failure for your appeal. Working with someone who is both a skillful negotiator and aggressive litigator is critical. You need to be represented by counsel who is willing, and able, to take your case to court if necessary.
Appealing Health Insurance Claim Denials
If you believe your health insurance claim was unreasonably denied, taking action is important. That said, the process can be complex. First, you should request an internal appeal; this must occur before the actual appeal can commence. This process requires the company to review your claim to identify anything they may have missed that lead to their denial.
In some cases, internal appeals are unnecessary. These include if you’re going to an outside review because either (1) you and the company waive the internal process or (2) you need immediate medical care.
Deadlines Play an Important Role in the Appeals Process
In most instances, you must appeal the denial within 180 days of receiving written notice. However, some insurance companies employ different rules. Review your policy documentation and confirm with your insurance company to identify their deadlines. An internal appeal typically takes 30 to 60 days to complete.
How to Appeal a Denied Medical Insurance Claim
Rules Matter
Each company has its own appeals process; it’s important to abide by their rules. Review your policy and contact your insurance company to submit your appeal appropriately. In some cases, it must be in writing. If so, send it certified mail so you have proof of delivery. Other companies may want you to complete your appeal through an online portal or even by fax. Requesting an appeal over the phone is not recommended, because you want to have written proof of your request. You should follow-up on all conversations with your insurance company by an email, summarizing your conversation.
Sometimes, appeals must be fast-tracked due to urgent medical need. In instances like this, a “peer-to-peer” review between your physician and the insurance company may be scheduled. Ask your physician to retain documentation of the call for later reference.
Drafting Your Letter Appropriately
Appeals letters are important. When done right, they can improve the chances of a reversal, allowing policyholders to receive treatment more quickly and save thousands of dollars. They also become part of a document package submitted in an external review, if necessary. Your letter must be accurate, discuss the reason for the denial, and state your case refuting the initial decision.
These letters should include:
- A summary of your medical history, diagnosis, and treatment
- The reason for the denial
- What you want from the appeal
- Why your request is justified. Cite the facts, statements from your doctor, and parts of your policy that support your request.
- Attachments: documents and specific medical records that support your claim.
If your insurance company does not make changes after reviewing your letter, you can request an outside review from the Oklahoma Insurance Department (OID), though some denials are ineligible for this process. These include:
- Denied treatments that are not covered benefits, even if you believe they are medically necessary
- Denials based on administrative issues, like not paying premiums on time.
Remember, coverages through Medicare, Medicaid, other federal plans, or your employer’s self-funded plan have a different appeals system.
How to Fight a Denied Health Insurance Claim: The External Review Process
Outside appeals are conducted by an Independent Review Organization (IRO) which is unaffiliated with your insurance company and has no financial interest in your case. IROs are usually consulting, accounting, or law firms with specific expertise.
Certified by the OID, IROs also have national certification. They must show they’re unbiased and engage qualified and independent reviewers. If OID determines that your case is eligible for an external review, it will randomly assign your appeal to an IRO.
You have four months from the insurer’s decision to ask for an external review. The IRO has up to 45 days after OID accepts your request to issue a decision. It may be delivered faster if you request an expedited review because of urgently needed treatment. All fees associated with IROs are covered by the insurance company.
External reviews look at denials based on coverage requirements for:
- Medical necessity
- Appropriate treatment
- Provider locale
- Level of care or effectiveness (including whether the proposed treatment is experimental or investigational).
IROs must consider all documents, records, and information provided, including medical or scientific evidence, the insurance contract, and any legal bases given for your denial.
IRO decisions are binding on both parties. If your review is unsuccessful, you may file a legal claim for bad faith against your insurance company. Insurance companies are required by law to act in good faith when handling legitimate policyholder claims. If you believe yours is not doing this, consulting an Oklahoma bad faith insurance lawyer is an important action step in resolving your issues.
Insurers must treat customers fairly and pay claims that should be covered. Unfairly denying or delaying the payment of valid claims could be the basis of a bad faith lawsuit. Oklahoma insurance law protects policyholders against companies focused on profitability as opposed to appropriate client service.
Engage a Bad Faith Insurance Claims Denial Attorney Today
Doug Terry Law Can Help You
Engaging the right insurance claim appeal lawyer is an important first step in addressing your denied claim. Doug Terry Law has been handling cases like this for decades. As experienced Oklahoma health insurance claim denial lawyers, our practice is dedicated to helping people like you who have been wronged by their insurance companies. We have a reputation for working tirelessly for those treated unfairly and illegally by their insurance companies.
Contact us today at (405) 463-6362 to schedule a free consultation. We are ready to leverage our experience and fight tirelessly to maximize your settlement.