Information for Consumers About the Claims and Appeals Process

My insurance benefit claim has been denied. What can I do?

If you believe your claim was inappropriately denied there are several things that you can do:

• Every health insurer has an internal review process. You can find out about that process by calling the number on the explanation of benefits (EOB) document that you received and asking for information on the appeals process for your health plan.
• Many health insurers have multiple levels of review. While this varies by company, most of the time you can appeal your claim more than once internally.
• Many health plans have independent outside medical experts who they will ask to review claims.
• Medicare beneficiaries must follow the process outlined in their Medicare handbook. For more information you can visit www.Medicare.gov or call 1-800 MEDICARE.
• Medicaid beneficiaries should call their state Medicaid office for information about the Medicaid appeals process. A list of state contact numbers is available by clicking here.
• If you have gone through all the internal review processes with your health plan and you still believe that your claim has been denied in error, you may have another option for appeal. 43 states plus the District of Columbia have external or independent review programs. This is a review process overseen by the state that provides an additional, legally mandated appeal. Click here for information about the program in your state. For a list of frequently asked questions and answers about the external review process click here.