3c. Health Insurance: Reviewing Your Statements & Appealing Denied Claims
Each insurance company has written policies and protocols on covered treatments for different types of cancer. During the course of treatment, a claim to the insurance company may be denied or a treatment plan may not be approved. Coverage may be denied for some of the reasons below:
The treatment or prescription is considered experimental.
Other available treatment options outlined in the company policy haven’t been tried.
An out-of-network provider was used.
A claim may be categorized as cosmetic or elective, such as prosthetics or breast reconstruction.
Appealing Denied Claims
Patients have the right to appeal any denied claim or treatment plan. The steps below offer guidance on appealing the denied claim:
Step 1
Call the insurer and ask for more information about the denial.
Step 2
Ask if the denied claim can be resubmitted with a letter of explanation from a medical provider.
Step 3
Request all denied claim information in writing and keep a journal of names, dates, and conversations with the insurer and cancer care team about the denial.
Step 4
Formally appeal the denial in writing. The social worker, medical providers, and Essentia Health financial counselor can assist with the formal appeal.