What do I do if my claim is denied?


If a claim is denied, there are a few basic questions you'll need to answer:

  • Was care received from an in-network provider?
  • Was the health care service a covered benefit?
  • Did you get all necessary referrals or prior authorization from your insurance company?

If you answered "yes" to all of the above, you may have justification to file an appeal, or file on the basis of medical necessity. If this happens, you have options:

  1. Most insurance companies have a written appeal process, so carefully follow the process they outline. This information should be available on your Explanation of Benefits (EOB), in documents provided your insurance company, and on the company's website. The information on your EOB will help you understand whether the claim was denied because the benefits of your plan don't cover the service received or due to lack of medical necessity.
  2. It is not uncommon for the appeals process to take 30-90 days.  Make sure that you communicate with the healthcare providers office and let them know that you are appealing the denial so they know that you are not ignoring any bills that you might receive during that time.
  3. Contact your insurance agent or your employer's insurance agent (if your insurance is through your employer). As a third party, agents can talk with health care providers and insurance companies in their terms and try and help you negotiate.
  4. If you are unable to get the help you need from the insurance company, contact the New Hampshire Insurance Department: http://www.nh.gov/insurance/consumers/index.htm.  The insurance department can provide assistance, including help with external appeals.
  5. If the appeal fails or is only approved for a portion of the charges and you've exhausted all other options, ask to speak with the provider's billing supervisor and offer a pay off a portion of the balance, such as $0.50 on the dollar off the balance if you pay within one month. If the provider agrees to these terms, ask to receive confirmation in writing.