How to Advocate for Yourself After a Health Insurance Claim Denial

August 7, 2024

Life is full of unexpected twists and turns.  The denial of your health insurance claim by your insurance company is one of those instances. If you have paid your insurance policy premiums on time, you would expect that your claim would be paid fully, and in a timely manner.  Receiving a letter of denial would not be something considered possible.

Unfortunately, actions like this are not uncommon — insurance companies deny claims every day. In situations like this, controlling what you can is a valuable mindset to adopt.  You cannot control what has already occurred, but you can control how you react.

Knowing what to do to appropriately advocate for yourself, your health and your future is incredibly valuable.

Consider speaking with an experienced denied health insurance claims attorney for guidance as you move forward.

Health Insurance Denials Aren’t Final

For many, receiving a health insurance claim denial letter is devastating. They immediately pivot into an emergency mode, trying to determine how they can pay for their treatment or what they can do in absence of it. It never occurs to them that other options exist.

But, they do.  In fact, health insurance denials are not final. As a policyholder you have the right to submit a letter of appeal requesting a review of the insurance company’s decision.

In order to be successful, there are a number of steps to take and information to include in your letter.  For many, working with a reputable health care claims denial attorney in Oklahoma is key to effectively managing this complex process.

Understanding the Denial

Perhaps the single most important factor is understanding why the insurance company denied your claim. This information will help you to structure your letter of appeal and appropriately address the issues at hand.

There are a number of reasons why insurance companies deny claims, including administrative errors (misspelled names, erroneous birth dates, and incorrect billing codes), medically unnecessary treatment, uncovered procedures, experimental treatments, and out-of-network providers.  Additionally, if your insurance company requires a pre-authorization for the treatment you received and you neglected to apply for it, they will likely refuse to pay your claim.

The reason for the denial will guide your next steps. For instance, if an administrative error is at the heart of the problem, you may be able to submit your claim correctly and have it paid. Other issues would require a more detailed and focused letter.

Building Your Case

Your Oklahoma denied health care claims attorney can advise you on how to structure your appeals letter, the first step in building your case. It is important to compose a straightforward and direct letter that addresses issues clearly and provides appropriate support.

Critical to building your case is having all of the information you may need. This includes your:

• Denial Letter
• Insurance Policy
• Claim Submission
• Medical Records
• Physician’s Correspondence (if any).

Being able to easily access this information as you draft your appeal letter can help you create a clear, concise, and accurate request.  It is also valuable to attach copies of any documentation to which you refer, to make it convenient for the individual reviewing your claim.

Also, you want to make sure to submit your appeal in the manner specified by your insurance company. While some companies have a special portal for this purpose, others may require you to email a specific department or contact person. Still others will want a hard copy mailed to them. In cases like this, you should send your letter certified with return receipt requested or express mail signature required. You want to have proof of delivery.

Finally, make sure you keep a copy of everything you send for your files. Do not send your originals as it is likely you will not receive these documents back from your insurance company.

The Appeal Process

While submitting a letter is the first step in the appeals process, it may not be the only or final action needed.

In fact, if your appeal letter is rejected, you can take your case even further.

If you have taken all of the steps possible with your insurance company and cannot resolve your claims denial, you may be able to file for an external review of your situation through the Oklahoma Insurance Department. You have four months from your insurance company’s denial to file for this.

First, you must identify whether you are actually eligible to take this step.  While denials because of medical necessity and appropriate treatment are eligible for an external review, those made because of administrative errors and non-covered benefits are not.

Once again, gathering all appropriate documents is important; with external reviews you have only one opportunity to submit your appeal. A health care denied claims attorney can help ensure you have everything you need.

Once you submit your application for review there is a 45-day window in which the review can be conducted.  At the end, a final decision will be rendered.  Keep in mind that the process can be fast-tracked when medical need exists.

When to Seek Legal Help

The appeals process is purposefully complex; because of this, most people simply don’t move forward. They are overwhelmed; knowing what to do, how to do it, and understanding all of the technical language is just too much to manage.

This is when it is valuable to engage the assistance of an experienced denied health care claims attorney. The guidance provided by this professional is invaluable as you move throughout the process. Not only can they help guide you through both internal and external reviews, but they can also help identify decisions made in bad faith and calculate damages resulting from it.

Contact Doug Terry Law for Assistance

Doug Terry Law has an outstanding reputation throughout the state for advocating successfully on behalf of their clients.  The firm was founded to provide individuals in Oklahoma the same quality legal advice as their insurance companies. In effect, they level the playing field.

In each case, Mr. Terry and his team leverage their decades of experience, taking time to understand the intricacies of the denial. They know how to manage cases like this and handle all aspects of internal and external reviews.

Contact them today at 405-463-6362 to schedule a free consultation. During this meeting they will review your situation and share how they believe they can help with your insurance claim denial.