Preparing for an Appeal

The appeals system has been put in place for people to ensure that if there has been error that it can be corrected. However, being prepared for an appeal will make it go much more smoothly. A few tips you should consider:

• If you don’t understand the reason for your claim being denied, start by calling or writing your health plan to ask for a full explanation. The information you need is contained on the explanation of benefits (EOB) document that you received that describes what the insurer is going to pay.
• If you believe there has been an error, sometimes you can resolve the matter with a phone discussion. If the facts are complicated it may be best to start by writing a clear letter that lays out all the facts. Be sure to include all relevant information, including your member number and your claim number.
• Engage your health care provider. Often your health care provider can help explain to the insurer the reason for a particular claim and may provide additional information that helps the insurer reach a different conclusion.
• If your health insurance is provided through your employer, you may wish to talk to your company benefits manager or human resources staff.