Appealing Denied Insurance Claims: An Overview

The process of appealing a denied insurance claim is complicated but can be effective if done correctly since there are numerous reasons for claims to be denied by an insurance company. The payer or insurance company receives thousands of claims everyday and the claim can be quickly denied if there has been an error in any aspect from diagnosis to medical billing and coding. The reason for a denied claim is given in the Explanation of Benefits or EOB and is the most crucial aspect when appealing a denied claim. Moreover, there is also a need to comprehend if the claim is worth appealing since a claim that amounts to just $1 is not worth appealing but one which is worth a substantial amount needs to be investigated. Here are some of the reasons for claims to be denied and how to go about appealing such denied claims.

Services not covered

The insurance company can rightly deny a claim if the services rendered to the patient are not covered under the insurance plan. In such cases there is not much a person or a medical biller and coder can do to get paid since this is a legitimate reason for denying a claim. Therefore it becomes important for a physician or health care provider to determine if the services provided are covered under the insurance plan before commencing to provide such treatment. There is no point in wasting time and money if such a scenario occurs and appealing and re-appealing would only result in denials and re-denials.

Errors in Clinical Documentation

Errors in documentation can lead to denied claims and such claims have a good chance of a successful appeal if there are no other reasons for the denial. These errors can range from not specifying the correct codes or even mistakes in spelling and procedure to be followed. The error can arise from the physician’s office or due to a mistake in medical billing and coding. These errors can easily be rectified by professionals who understand the CPT codes and ICD codes involved in the procedure. However, time is of essence here and if the claim is not appealed within the stipulated period of time, it cannot be appealed after such time has elapsed after the claim denial.

The Appeal Process

The process of appealing a denied claim can differ from one payer to another and it is important to understand the correct procedure for appealing the claim in order to be successful. If the claim is not appealed in a manner which the policy describes, it can be turned down by the payer. For instance, the procedure for appealing a denied claim by Medicare is different from other private insurance companies. Even under Medicare there are different ways to appeal a claim which depend on the type of coverage chosen. There are different procedures for appealing a claim for Original Medicare, a Medicare Health Plan, and a Medicare Prescription Drug Plan. The appeal forms are available on the Medicare website and can be downloaded or printed for appealing a claim. A Medicare Redetermination Request form is available on the CMS website and can help you understand the procedure and file a claim according to this form.

Medically necessary claims

In many cases appealing a denied claim hinges on the fact if the treatment provided is medically necessary or scientifically proven. This means that the insurance company regards the claim as medically unnecessary or the treatment is scientifically not proven to provide better health outcomes for the patient. In such a case the help of recognized medical journals such as can be used as evidence to prove the necessity or the scientific viability of the treatment. Physicians can make an undeniable claim based on such evidence in order to get paid in a timely manner.

Medicalbillersandcoders: an ideal ally to handle claim appealing process
The reason and the process of appealing a claim can be time consuming and complex since there are many grounds on which the claim can be denied. Some of the common reasons include policy limitations or guidelines, untimely appeals of claims, denied authorization for prescription drugs, denied the transportation to an Emergency Hospital, services received without a referral or authorization, and denied due to the physician being out of network.
The complexity in the reasons for denials and the appeals process makes it a task in itself requiring in-depth knowledge of such processes. This problem can be solved by medical billers and coders who are experienced and know the usual pitfalls and reasons for claims being denied. Utilizing the services of medical billers and coders can help physicians and patients in saving time and money which have become an important issue in the light of recent health reforms.

For more information about better solutions for issues related to appealing denied claims and professional medical billing and coding services, please visit, the largest consortium of medical billers and coders in the United States for all specialties. Our medical billing experts – who are adept at accurate charge-capture, intricate procedure coding, electronic filing of claims, patient billing, multi-tiered appeal process, denial elimination initiatives, and compliance standards – have been crucial to physicians/clinics/hospitals’ operational efficiency and revenue maximization.