Just because your insurance company denied your medical claim doesn’t mean all is lost. There are ways to appeal the ruling and get the claim covered; it just might take a little homework.  

“There are different reasons a claim can be denied,” explanis Erin Moaratty, chief of external communications for the non-profit Patient Advocate Foundation, who suggest before fighting a claim, you check the details of your insurance’s appeal policies.

According to medical insurance experts, the insurance company must provide a reason it won’t pay a claim. In some cases, the payment could be rejected because the doctor coded a procedure or treatment wrong, while in other situations it may be because the carrier deemed the treatment as investigative or experimental.

“Understanding why you were denied gives you a heads up on your next step,” says Moaratty. For instance, if the claim was coded wrong, all it may take is having the doctor resubmit the claim to get payment.

According to Kevin Flynn, president of HealthCare Advocates, when hit with a denied claim, your first stop should be back to the doctor’s office. He says a lot of the times it is a doctor error and nothing needs to be done to get payment. But if it was denied for another reason, then the consumer has to engage in the appeals process.

In most cases, health-insurance providers offer patients a first and second level appeal and then an external review. The external review, which in handled by a third party, is the end of the road for most consumers. Lose that and the only other option is litigation, says Flynn.

After determining why the treatment was denied, Flynn advises you formulate an argument as to why the insurer should cover the expense.

If the insurer denied a claim citing it as experimental, Flynn says you need to send a letter to the insurance company from the doctor stating the reason why the treatment, procedure or medicine was necessary. Sending a letter instead of trying to fight the claim over the phone is advantageous because it creates a paper trail that you can reference if necessary in the future.

According to Patient Advocate Foundation, the appeals letter should include  a letter from the doctor addressing the specifics of the illness, any key information from your medical records and any articles from peer-reviewed medical journals that can support your claims.

Experts say it is ideal to get the treating doctor involved in the appeals process from the start. Having the support of a doctor will validate your argument, and hopefully get results quicker from the insurance company. Consumers can also turn to non-profits like Patient Advocate Foundation for help. The non-profit has served 83,000 patients last year alone.

The amount of time a patient has to appeal and the different levels of appeals vary by insurance company.

The appeals process can be overwhelmingly for consumers. Non-profit organizations can help navigate the process and provide tips for appealing for free. Consumers can also turn to a paid advocate for help. Flynn says hiring an advocate tends to costs around a flat fee of $500 or 30% of the saving; he adds that hiring an advocate typically makes sense if the claim you are fighting is at least $800 to $1,000.  Once you do file appeal, he says to follow up about a month later if you haven’t heard from the insurer. If you still don’t get results, you can try contacting your state’s insurance commissioner.

There are ways to avoid getting caught in a situation of having to battle a health insurer to cover a claim.  While it’s normal to trust a doctors’ prescribed treatments, you need to be your own advocate from an insurance perspective.

 “Always check,” says Moaratty. “The doctors can’t be responsible for knowing your plan. As a policy holder you have to know what the plan covers.”