Appealing an Insurance Claim

What is an appeal?

An appeal is a written request to your insurance company for further review of a denied claim or service.  How you appeal a denied claim will vary among health plans.  Call your insurance company and tell them that you wish to appeal a claim that was denied and that you need to know what their appeal process requires. 

How do I appeal if my claim is denied?

Often a claim denial can be attributed to errors or incomplete information.  In these cases, you or your healthcare provider can simply make the necessary corrections, attach additional information about why the equipment/services are needed and then resubmit the claim. 

Even if you do everything correctly and completely, your insurance company may still deny your request for reimbursement.  It is important for you to remember that an initial denial is not final and may be overturned if you appeal.

Here are some questions to ask your insurance company representative:

  • Why was the claim denied?
  • Who must initiate the appeal (you or your provider)?
  • What do I need to send and to what address?
  • How long will it take to process the appeal?

In most cases, you or your healthcare provider will be required to write an Appeal Letter.  In this letter, be sure to include information about the medical reasons why you need to pump breast milk and/or why you need the services of a lactation consultant.  This could be if your healthcare provider has indicated that your baby needs breast milk (benefits of breast milk, formula allergy) or if your baby has some other special need that requires you to pump your breast milk. 

A Letter of Medical Necessity from your healthcare provider may or may not be required with your appeal.  Even if not required, a letter from your healthcare provider (baby’s pediatrician/neonatologist or your lactation consultant) can be very helpful in supporting your position.  No matter what type of insurance you have, it is your right to appeal a denial.

Sometimes a claim denial is due to specific exclusions or restrictions included in a particular health plan.  Specific exclusions or restrictions are services or products that are not covered by your health plan.  If your claim is denied because the service or products are specifically not covered by your health plan, you may need to file a grievance.  As with the appeal processes, the process for filing a grievance will vary from health plan to health plan.  Be sure to call your health plan’s customer service department to obtain the specific details.  Calling for the specific details is important when submitting a claim denial appeal or filing a grievance.

As a health plan customer, you have the right to be heard; keep in mind that the insurance company also has the right to approve or deny your request.  Some tips for communicating with your insurance company are also provided to help you get the most out of your healthcare benefits.  It is important to know that appealed claims are typically successful if the appeal letter and documentation includes information that supports the medical need.