How to Appeal a Rejected Claim

by Jacky G.

Whenever you deal with an insurance company, keep copies of all the paperwork. Make a copy of your submitted claim and all supporting documents. This will ease the process of filing an appeal in the event that your claim is denied. If the insurance company rejects the claim, the first thing to look for is the explanation of the denial. Typically, this will be included in the letter of denial.

If you cannot locate an explanation, call your insurance company and ask them to send you a written explanation of the denied claim. You should also request that they send you the name, medical license number, and state issuing the medical license of the person who denied your claim. Request the insurance company’s instructions for filing an internal appeal.

Thoroughly review the explanation of the denial. There are a few common reasons why an insurance claim for speech therapy may be denied. The insurance company may not cover all services or they may only cover a certain number of visits, for example. If the explanation for denial does not make sense to you, make an appointment with your employer’s human resources department to discuss your policy.

Let your child’s speech therapist know that your insurance company denied the claim. Ask her to write a letter in support of the speech therapy, stating explicitly why your child requires treatment. Obtain a letter of referral to a speech therapist from your child’s pediatrician.

Create a Letter of Appeal

Write a letter of appeal in accordance with the insurance company’s instructions for an internal appeal. Include all the relevant information, such as your child’s name, the health plan identification number, the dates of service, and a concise explanation of why the claim should not have been denied. Include all supporting documents, such as a copied page from your insurance policy that proves that the treatment should have been covered.

Send the appeal letter to the appropriate department in your insurance company. If you do not know the proper department, call the insurance company and ask for this information. Mail the appeal letter via certified mail, return receipt requested (always keep the return receipt!).

Follow-up with your Insurance Company

Contact the insurance company regularly to check on the status of your appeal. Every time you call the insurance company, keep a record of it. Write down the full name, title, and department of the representative you contacted, as well as a brief synopsis of the conversation.

If your appeal is denied or the insurance company fails to address it in a timely manner, contact your state’s department of insurance. The National Association of Insurance Commissioners can tell you which department to contact in your state. If your state does not have a specific office for insurance cases, contact your insurance company to request an independent review. Only resort to this option if you have already exhausted all possible internal appeals within the insurance company; otherwise, your request will simply be denied.

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