If an insurance claim is rejected, immediately review the denial letter for reasons, gather supporting evidence (photos, records), and file a formal internal appeal within the required timeframe. If the appeal fails, request an external, independent review, contact your state's insurance department, or consult an attorney.
Steps to Take After a Claim Denial
The first thing you can do is ask the insurer to review its decision. It is well within your rights to ask for them to undertake an “internal review”. If possible, we recommend you provide any additional evidence and/or arguments to support your insurance claim.
Here are some tips for handling rejected claims:
Since insurers base premiums on how likely policyholders are to file a claim, a claim that's denied can cause your rates to go up — though not as much as if the claim was approved. Even discussing a claim with an agent, without actually filing it, can impact your premiums.
Six Tips for Handling Insurance Claim Denials
You can ask that your insurance company reconsider its decision. Insurers have to tell you why they've denied your claim or ended your coverage. And they have to let you know how you can dispute their decisions.
While most claims remain on your record for five to seven years, the exact length of time depends on a few factors, like your insurance company and the severity of the claim. Usually larger, more expensive claims stay on your record for longer, whereas smaller, less expensive claims might be removed earlier.
In 2023, roughly one third of all in-network claims made to AvMed were denied by the medical insurance company. In this year, AvMed and United HealthCare were the medical insurance companies with the highest denial rate for in-network claims in the United States, at 33 percent each.
When talking to an insurance adjuster, avoid admitting fault, speculating on the cause or extent of injuries/damages, giving recorded statements without legal advice, and volunteering extra information like past injuries or unrelated details, as anything said can be used to minimize your claim; instead, stick to basic facts, remain polite but brief, and consider getting legal counsel. Don't sign anything without review, and avoid saying you're "fine" or "okay" immediately after an incident.
If you are still unsatisfied with the decision, you can appeal the insurer's decision to the Financial Ombudsman – within 6 months of receiving the insurer's response to your complaint. The Financial Ombudsman is an independent organisation that can help you resolve disputes with your insurance company.
One of the most common reasons for claim rejections is when claims are submitted, and the patient's insurance policy has been terminated. It is not uncommon for patients to change plans based on regular enrollment cycles or changes in coverage options.
(b) Upon receiving proof of claim, every insurer, except as specified in subsection 2695.7(b)(4) below, shall immediately, but in no event more than forty (40) calendar days later, accept or deny the claim, in whole or in part.
Submit an appeal.
This is a written notice challenging a denial or requesting an exception to the plan's policies. Even out-of-network providers can appeal, or if it was your error that led to the denial. Contact the plan for details about its appeal process and filing deadlines.
To win a civil case, you need evidence that proves each legal element of your claim by a preponderance of the evidence. This typically includes documents, witness testimony, physical or digital proof, and sometimes expert opinions.
Here, we discuss the first five most common medical coding and billing mistakes that cause claim denials so you can avoid them in your business:
Request a review by the insurer
You can request that the insurer review the decision. In your request, include any additional information that may help. The insurer must respond in writing within 14 days, either overturning, modifying or maintaining the original decision.
Contact your insurance company
If you still feel that your claim was unfairly rejected, contact your insurance company and tell them you're unhappy. All insurance companies are required by law to have a formal complaints process, so following this process will get you the fastest possible resolution.
10 Common Reasons Health Insurance Claims Are Denied