Can I appeal an insurance claim denial?

Before you start an appeal, be sure that there is a solid basis for your request. If so, you’ll want to tell a concise and compelling story, substantiated by facts, regarding the terms of the benefits and coverage on your plan. Remember that you are appealing for what the plan is obligated to deliver that qualifies as medically necessary and is not specifically excluded from your health plan.

Review the plan’s evidence of coverage (EOC) for any parameters established to exclude, limit, or narrowly define the service you want funded. This lengthy document can often be found in your plan’s member portal or via call or live chat with customer service. For some employer-based plans, it is available only from the HR department. The EOC will typically list excluded diagnosis or treatment types.

For more information about dealing with insurance claim denials, see our article Insurance Claim Denials and Appeals 101.