Key points
- Some denials are mistakes in the paperwork, such as a wrong code, a missing detail or a duplicate claim, and a corrected claim can fix them.
- Ask for the diagnosis and treatment codes in writing. Asking for them is not an appeal and does not start or stop any clock.
- Fixing a claim does not pause your deadline to appeal unless the plan tells you so in writing, so keep the appeal ready.
Some denials are not real decisions about your care. A billing office typed the wrong code, left out a detail, or sent the same claim twice. If your notice points to a paperwork problem, a corrected claim or a reprocessing request may get the claim paid without an appeal. Try that, but keep your appeal ready, because the deadline to appeal keeps running while you do.
What this means
A denial that comes from the paperwork is different from a denial that says the plan will not cover the care. The first kind is usually fixed by the provider’s billing office or by a call to the plan. The second kind needs an appeal.
Your denial notice or explanation of benefits should give a reason and often a short code. Typical paperwork reasons are a wrong or missing diagnosis or procedure code, a wrong member number or date of birth, a duplicate claim, or missing information. These are covered in more detail on the pages about coding and billing errors and who has to fix each kind of denial.
Two different things can happen when you ask the plan to look again. A reprocessing request asks the plan to run the same claim again, usually because the plan made a mistake. A corrected claim is a new version of the claim, sent by your provider’s billing office, with the error fixed. Only the provider’s office can send a corrected claim. You can ask for reprocessing yourself.
What to do
- Read the reason on the notice. Find the reason and the code. If it points to a paperwork problem, go on. If it says the plan decided the care was not medically necessary or is not covered, skip to the internal appeal.
- Write down your appeal deadline now. For job-based plans and most individual plans the federal minimum is 180 days after you receive the denial notice. Your plan may allow more. Check the date on your notice, which controls. The deadline calculator can help.
- Ask for the codes in writing. After a denial, a plan that is not grandfathered must give you the diagnosis code, the treatment code and their meanings on request. Compare them with what your doctor did and what your records say.
- Call the provider’s billing office (your provider’s step). Tell them the claim number and the reason on the notice. Ask: “Is this a coding or data error? Can you send a corrected claim?” Ask when they will send it, and write down the name of the person.
- Call the plan and ask for reprocessing (your step). Use the numbers on your card. Ask whether the claim was processed correctly, whether a corrected claim is needed, and when you can expect a result. Ask for a reference number. The call script for asking for reprocessing and the call log help with this.
- Set a date to check back. Pick a date at least a month before your appeal deadline. If the claim is still denied on that date, file the appeal.
- Ask for a written result. A phone answer can be undone. Ask for a new explanation of benefits or a letter that shows what happened.
What the plan may say, and what to say back
“Your provider needs to resubmit the claim.” Ask which detail was wrong, and ask your provider’s billing office to send the corrected claim. Ask both sides to confirm the date in writing.
“We cannot discuss this with you, only the provider.” Ask what the plan needs from you to speak with you, such as a signed form, and ask for that form. Ask for your request to be noted.
“We have reprocessed it and the answer is the same.” Ask for the reason in writing. If it still looks wrong or it is a real coverage denial, file an appeal.
The rule
A plan that is not grandfathered (a plan in place since March 2010 that has kept its old status) must provide the diagnosis code, the treatment code and their meanings “as soon as practicable” on request. The plan cannot treat a request for these codes as an appeal or as a request for external review. See Code of Federal Regulations (CFR), title 29, section 2590.715-2719(b)(2)(ii)(E).
If you sent a request for approval before care in the wrong way, but it reached the unit that handles benefits and named you, your condition and the treatment, the plan must tell you the correct procedure within 5 days (24 hours if the case is urgent). See 29 CFR 2560.503-1(c)(1).
Watch for
- A call is not an appeal. Unless the plan tells you in writing that it has treated your request as an appeal, assume your deadline to appeal is still running.
- Missing information is not always a paperwork slip. If the plan says it needs more information, the notice should say what and why. For a claim that is not urgent, the plan must give you at least 45 days to send it. If it is urgent, you get at least 48 hours.
- Medicare, Medicaid and other public coverage use their own notices and deadlines. Read the notice, and see the pages on Medicare and Medicaid and children’s coverage.
- Do not pay twice. If your provider says you owe money while a corrected claim is pending, see the bill while you appeal.
What next
- How to file an internal appeal: the next step if the fix does not work or the denial is about coverage.
- Patient appeal and provider appeal: run both: how to work with your doctor’s office so that nothing is missed.
- How to keep a call log: the record that protects you if the plan later says nobody called.