My Claim Was Denied

Receiving a denial from your health insurance company can be frustrating and concerning, particularly when you need important medical care. However, insurance denials are not always final decisions. Understanding why your claim was denied and knowing your appeal rights can help you challenge inappropriate denials effectively.

Understanding Denial Reasons

Insurance companies may deny claims for various reasons, each requiring a different approach to resolve:

Medical Necessity Determinations:

Your insurer may determine that the requested service isn't "medically necessary" for your condition. This is one of the most common reasons for denials. Medical necessity denials often require additional clinical documentation from your healthcare provider to demonstrate why the treatment is appropriate and necessary for your specific situation.

 

Not a Covered Benefit:

Some services may not be included in your plan's covered benefits. In these cases, it's important to carefully review your plan documents to verify whether the service should actually be covered. Sometimes insurers incorrectly categorize services or misinterpret their own policy provisions.


Prior Authorization Requirements:

Many plans require pre-approval (prior authorization) for certain services, procedures, or medications. If you received care without obtaining required authorization, the claim may be denied. In some cases, retroactive authorization may be possible, particularly if the service was urgently needed.

Network Restrictions:

Most plans offer better coverage (or only cover care) when you see in-network providers. Out-of-network care often results in higher costs or claim denials. However, there are exceptions for emergency care and situations where appropriate in-network providers aren't reasonably available.

Coding or Billing Errors:

Sometimes denials result from simple administrative errors in how the service was coded or billed. These can often be corrected by working with your provider's billing office to resubmit the claim with proper documentation.

Coordination of Benefits Issues:

If you have more than one insurance plan, confusion about which plan should pay primary can lead to denials. Providing clear information about all your coverage can help resolve these situations.
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Your Appeal Rights

All health insurance plans must provide a process for members to appeal coverage denials. Understanding these processes and timelines is crucial for a successful appeal:

  1. Internal Appeals with Your Insurance Company: The first step is usually an internal appeal directly to your insurer. You generally have 180 days from receiving the denial notice to file this appeal. Your insurer must review your case and respond within specific timeframes:


  1. 30 days for pre-service claims (treatments not yet received)

  2. 60 days for post-service claims (treatments already received)

  3. 72 hours for urgent care situations


During this process, medical professionals who weren't involved in the initial denial should review your case. Many insurers offer a second level of internal appeal if the first is unsuccessful.


  1. External Reviews Through the Connecticut Insurance Department: If your internal appeals are unsuccessful, you may qualify for an independent external review. This applies specifically to denials based on medical necessity, experimental/investigational treatments, emergency services, and other clinical determinations. The external review is conducted by independent medical professionals with no connection to your insurance company.

To request an external review in Connecticut, you must submit a Request for External Review form to the Insurance Department within 120 days of your final internal appeal denial. For urgent situations, expedited reviews are available with decisions provided within 72 hours.

  1. Legal Remedies: In certain situations, particularly with employer-sponsored plans, legal action may be possible after exhausting other appeal options. This typically applies to plans governed by the Employee Retirement Income Security Act (ERISA).

How OHA Can Help

Expert Review & Analysis:

We thoroughly review your denial letter and insurance plan to understand the specific reason for denial and identify the strongest arguments for reversal. Our team examines your plan documents to determine whether the denial conflicts with policy provisions or regulatory requirements.

Evidence Gathering & Documentation

Our advocates help gather supporting documentation to strengthen your appeal, including:

  • Medical records

  • Physician statements

  • Relevant research


We understand what evidence is most persuasive for different types of appeals

Strategic Appeal Letters

With extensive experience challenging denials, we craft effective appeal letters that address the insurer's specific reasons for denial while emphasizing the medical evidence supporting your claim. We know how to frame arguments that resonate with insurance reviewers.

Process Navigation & Compliance

The appeals process involves multiple steps, deadlines, and procedural requirements. We guide you through each stage, ensuring all requirements are met and deadlines are observed to prevent technical difficulties from undermining your appeal.

Direct Advocacy

With your authorization, our advocates can communicate directly with your insurer on your behalf. This often leads to faster resolutions and ensures your rights are fully represented throughout the process.

A patient's mother contacted OHA because the insurance carrier denied residential psychiatric mental health services for her child. She strongly felt her child needed intensive care and asked OHA what she could do. An expert case manager was assigned, and OHA filed the appeal, which resulted in a determination that the denial of services was overturned. As a result, 23 days of residential stay was paid by the insurance carrier. Savings for the consumer $85,100.

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