What to Do if a Claim Is Denied

If a health insurance claim is denied, the following steps may help you resolve the problem:

• Keep copies of all correspondence (such as letters and e-mails) with the insurance company about the claim. Note the claim number and policy or procedure code on all correspondence. Also, note the name of any customer service or claims representative you speak with on the telephone.
  
  
• Call the insurance company to find out why the claim was denied. If it is still unclear, study the explanation of benefits form. In some cases, the denial may be the result of a claim being improperly recorded (such as a service being omitted by mistake).
  
  
• Check the facts. Review the policy to make sure that pre-certification, authorization and other procedures required by the insurer were followed. For example, claims for prosthetic bras, implants and wigs may need a copy of the prescription and the bill.
  
  
• Ask your health care provider for help if fees, charges or procedures are questioned. Most providers and their staff are used to working with insurance companies and can help answer questions. Ask the provider to write a letter to the insurance company recording and justifying the charges or procedures. Be sure to keep a copy of this letter.
  
  
• If the claim is denied because the insurance company says that a treatment is experimental or under study, ask your provider to help. If he/she can give the insurance company evidence that the scientific literature supports the use of a certain treatment, then technically, it cannot be called experimental. Your provider can get peer-reviewed studies or reports and support letters from other oncologist using the same procedure. National patient support organizations can also help.
  
  
• Ask for a formal review of the denied claim. Often, claims that first were denied are paid in later reviews. If this fails, ask for an appeal of the review using outside cancer experts to review the medical records and claim.

If these steps fail to get payment for a claim that you and your providers believe is justified, a final option is to contact a lawyer. National patient support organizations can help identify lawyers in each state who specialize in cancer-related insurance issues. The Patient Advocate Foundation offers help resolving problems as well as help with insurance issues involving insurers, employers and creditors.