Key points
- Check two things first: whether the care is urgent, and whether care is about to end.
- Do not pay yet, and do not throw anything away.
- Write down the date on the notice and the date it reached you.
- Call your doctor's office early; they can often move faster than you can.
You have just been told no. The next two days are for slowing down and doing a few things in order. A denial is a decision, and your plan can be asked to look at it again. For most private plans the federal minimum is at least 180 days after you receive the notice to file an appeal (check the date on your notice, which controls). So the first 48 hours are about protecting your options, not about winning.
What this means
Almost nothing is lost by taking two days. There are two exceptions: care that cannot wait, and care that is about to end. In those cases the clocks run in hours or days, so check them first. Everything else is gathering paper, writing down dates and making one or two calls.
What to do
- Check whether the care is urgent. This is yours and your doctor’s step. Care is urgent when waiting could seriously harm your life, your health or your ability to recover, or when your doctor says waiting would cause severe pain that cannot be managed without the care. If it is an emergency, call emergency services first. If not, ask your doctor to tell the plan the request is urgent. Private plans must then decide as fast as your condition needs and no later than 72 hours (check the date on your notice, which controls). The urgent appeal triage tool walks you through it.
- Check whether care is ending. If the letter says a hospital stay, nursing facility stay, home health service or Medicaid service is ending or being cut, the deadlines are much shorter. In Original Medicare you ask the Quality Improvement Organization to review a hospital discharge no later than the day you leave. For nursing facility or home health services you ask by noon of the day after you get the notice. In Medicaid, asking for a hearing before the date the change takes effect can keep services going. Read the fast appeals guide for Medicare or the guide on keeping treatment going today, not next week.
- Do not pay yet. An Explanation of Benefits (EOB) is a statement, not a bill. If a bill has arrived, call the billing office, say the claim is being disputed with your plan, and ask them to put the account on hold and confirm that in writing. The bill while you appeal guide explains what else to ask for.
- Do not throw anything away. Keep the letter, the envelope, the EOB, any bills, pharmacy printouts, portal messages and text messages. Put them in one folder, paper or digital. Write on copies, not originals.
- Write down two dates. The date printed on the notice, and the date it reached you. Different programs count from different dates, so you want both. Put the earliest possible deadline on your calendar, and use the deadline calculator to turn it into a date.
- Call your doctor’s office. This is their step with you. Ask whether they have seen the denial, whether they can ask for a peer-to-peer review (a phone call between your doctor and the plan’s reviewing doctor), and whether a coding or paperwork error can be fixed and the claim sent again. A short note to the doctor’s office can help.
- Read the letter once, for four things. What was refused, the reason given, what the plan says you can do next, and the deadline. The guide to reading a denial letter goes line by line.
- If you call the plan, call to learn, not to argue. Ask what the decision is called, what reason it used, and for a reference number. Write down the name, date and time. The first call script has the questions.
What the billing office or plan may say, and what to say back
“The balance is due now.” Say: “This claim is being disputed with my insurance plan. Please hold the account and confirm that in writing.”
“You will have to speak to the insurance company.” Say: “I will. Can you tell me exactly what was sent to them, and whether your office can ask for a review of the decision?”
“We cannot discuss this by phone.” Ask for a written explanation or a portal message, and note the date you asked.
The rule
When a doctor who knows your condition says a private plan claim is urgent, the plan must treat it as urgent and decide as quickly as your condition requires, and no later than 72 hours. An urgent decision may be given by phone first, but a written notice must follow within 3 days. Source: Code of Federal Regulations (CFR) Title 29, section 2560.503-1(f), (g) and (m), the federal claims regulation. Check the date on your notice, which controls.
Watch for
- It may not be a denial. A rejected claim or your ordinary share of the cost needs a different response. See denied, rejected, or just your share.
- A phone call is not a notice. If someone told you no by phone and nothing came in writing, ask for the denial in writing.
- Medicare and Medicaid clocks differ. The 180 days above is for private plans. Public programs have their own deadlines; see appeal deadlines by coverage type.
- Changing treatment is a medical decision. Talk to your clinician before you stop, switch or delay anything.
What next
- Work out what you are holding: denied, rejected, or just your share.
- Find out who needs to act first: whose job is it to fix this.
- Learn how the clock is counted: how deadlines are counted.
- Use the first 48 hours checklist to tick these off, or go to read your denial letter.