Collaboration in Civic Spheres

State issues online guide to appealing health claim denials

by Matt Rosenberg April 29th, 2011

SUMMARY: The Washington state Office of the Insurance Commissioner has published an online consumer guide to appealing denied health insurance claims. It includes sections on how to correctly launch your appeal, traits of successful and unsuccessful appeals, a detailed summary of consumer best practices in appealing denied health care claims, and a templated work sheet for tracking calls, e-mails and step-by-step results.

BACKGROUND: Produced with funds from the U.S. Department of Health and Human Services, it will be translated into Chinese and Spanish, promoted at events statewide, and updated as laws and regulations change. “Washington is the first state in the country to provide a detailed online guide for consumers on how to appeal a health insurance denial,” said Insurance Commissioner Mike Kreidler, in a statement.

KEY LINK: Guide to appealing health insurance claim denials, Washington Office of the Insurance Commissioner

KEY COMPONENTS

  • The “Where To Start” section advises helps consumers figure out how to use the right terms and choose the right course of action. Key first steps are to determine what kind of health plan they have, who regulates it, and whether they’re appealing a “pre-service denial” or a “post-service denial.” It’s smart to already have a printed out copy of the guide’s “Ïmportant Information Worksheet” at this stage, to fill in as you go along. The “Where To Start” section also advises consumers to begin with an internal appeal to their health care plan and then if necessary appeal the denial to a designated independent reviewer. It also explains what rules and deadlines apply for an urgent appeal of a pre-service claim denial.
  • Common Traits of Successful Appeals” includes tips on how to best state your case, and how to underscore the necessity of the procedure and the provider chosen, in cases where your health plan denies the claim by categorizing it as “experimental” or as “out-of-network.”
  • Common Traits of Unsuccessful Appeals includes tips on presentation and information pitfalls, and on limitations on to a health plan’s contractual responsibilities.
  • The guide also provides a valuable summary of recommended best practices, including interacting with health providers and health plans, extending payment deadlines for pending bills, and filing an appeal with the state Office of the Insurance Commissioner.
  • The guide also emphasizes the importance of thorough record-keeping, and provides templated tracking form consumers can use to note their calls and e-mails in their appeals of denied health insurance claims.

Matt Rosenberg is founder and editor of Public Data Ferret, a project of the non-profit Public Eye Northwest.

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