As an expat in Mexico, having to appeal a denied health insurance claim can be a real pain.
Whether it’s full or partial denial, you need to know why and what to do to appeal.
In this post, we’ll cover why denials happen and the process of appealing a denied claim, and give you some tips to help get your money reimbursed.
In short, we’re going to show you exactly how to appeal a denied health insurance claim.
Why Insurance Claims Get Denied
Here are some common reasons claims get denied:
Undisclosed pre-existing conditions: If you have a condition you didn’t disclose when you applied for your policy, your claim for that condition will be denied if found out. This can – and DOES – happen.
General policy exclusion: Every policy has exclusions. For example, elective or cosmetic surgeries, podiatric care, over the counter drugs, and homeopathic treatment, just to name a few. If your claim falls under an exclusion, it will be denied.
You reached the maximum benefit: Your policy may have limits on certain benefits, such as 30 physical therapy sessions per year. If you go over the limit outlined in your policy, any additional sessions will be denied.
Claim wasn’t medically necessary: This is usually for pre-op testing that isn’t considered standard or necessary for the procedure. For example, in Mexico, it’s standard for some pre-operative testing to include a dental cleaning, but this is not considered medically necessary and will not be covered. Another claim that would be denied due to not being medically necessary would be a second assistant in the operating room.
Medication isn’t approved by the FDA: There are medications that are approved to be used for a specific diagnosis but are commonly used for other medical ailments. These are not covered by the policy as they aren’t medically recognized for a different use.
Difference between a Partial and Full Denial
This is pretty straightforward, but understanding the distinction is important.
A partially denied claim is when part of the claim is approved and part is denied due to general policy exclusions.
This happens often with medication claims. Because so many medications are available over the counter in Mexico, it’s very likely a portion of your pharmacy receipt will be denied because of those medications.
Another reason for a partially denied claim is if a procedure was over the UCR (usual, customary, reasonable) costs.
If you don’t pre-certify a medical procedure and decide to pay out-of-pocket directly, there’s a risk of being overcharged – and those overages will not be covered.
The eligible costs will be covered by your policy, but the excess will not be. And when this happens, it’s not something that can typically be appealed. The result: You will be out all that additional money.
If you get a denied claim, review your Explanation of Benefits (EOB) to see why it was denied.
If you need clarification or want to discuss the option to appeal, contact your broker right away to ask about starting the process.
NOTE – If you realize your policy doesn’t cover your claim or you’ve reached your maximum benefit, it isn’t worth it to try to appeal the denial. Only appeal a denied health insurance claim if you think the decision was wrong.
Steps to Appeal a Denied Health Insurance Claim
#1 Review Your Insurance Policy
Reread your policy for general and pre-existing exclusions. Understand the appeals process outlined in your policy.
#2 Gather All Supporting Documents
If you think your claim was denied in error, gather all your supporting documents. Get them all together FIRST because you need to submit them at one time.
If the insurer needs additional information, they will request it, but it’s better to have everything sent in once.
Note deadlines for submitting appeals, such as how long after you received the denied EOB that you can appeal.
Also, find out the insurer’s timeline for reviewing an appeal. If it’s 60 business days, they will typically take the full 60 business days.
#3 Talk to Your Broker
Discuss appealing the claim with your broker.
Ultimately, it is your decision to appeal a denied health insurance claim or not. If you feel it was done in error, don’t let anyone talk you out of it – not even your broker.
If you go ahead with the appeal, ask your broker for a template or outline of an appeal letter you can follow.
#4 Contact Your Doctor
The next step is to request your doctor’s professional medical notes outlining why the procedure was medically necessary.
Keep in mind that doctors might not want to do this or they may charge a fee to provide you with this information. They may even stop responding to you.
When you reach out, make sure to explain your situation calmly and in detail so they understand you are not questioning their medical decisions, but rather, it’s an insurance company issue.
#5 Craft Your Appeal Letter
Once you have all your supporting documents and your doctor’s medical notes, sit down and draft a formal appeal letter.
You can write this yourself or ask your broker if they can provide a template.
Clearly state your name, policy number, patient name (if different from the policyholder), and the denied claim number(s).
Address the specific reasons for denial mentioned in the EOB or denial letter.
Provide clear and concise arguments, citing relevant policy clauses and medical evidence as to why the claim decision should be reversed.
Be professional and polite, but firm in your request for reconsideration.
Provide the doctor’s detailed medical notes and any other supporting documentation, such as test results, medical history records, or other examples of the same condition.
#6 Submit Your Appeal
Follow the instructions carefully in your policy for submitting the appeal to avoid any delays.
Make sure to keep copies of all correspondence.
Most insurers have a 60-business-day time period to review your appeal, and they will likely take all that time.
#7 Follow Up
If you don’t receive a response within the timeframe specified in your policy, follow up with your broker and the insurance company.
Be prepared to provide additional information or documentation, if requested.
And be patient. (We know that’s often easier said than done, especially when you were expecting to be reimbursed already.)
Appeals is a closely reviewed process and takes time for insurers to look over all the information they’ve been given.
Sometimes, a longer response time may indicate that the decision is leaning in your favor.
If the decision is still a denial, look into arbitration options if you feel you should continue.
The wording for this can be found in your policy.
Keep in mind that your broker may need to remove themselves from your case at this point, as lawyers will be involved, and your broker may not want that liability.
Tips for a Successful Appeal
- Seek assistance from your insurance broker. They can provide guidance and support throughout the appeals process.
- Enlist the support of your healthcare provider to provide additional medical evidence. This is key when appealing a claim. It’s important to discuss with your doctor what you need and why.
- Be persistent and don’t give up easily. Appeals can take time and effort, but it’s worth pursuing if you believe your claim was wrongfully denied.
- Know your rights as a policyholder. Make your policy work for you and get the most out of your coverage.
We get that appealing a denied health insurance claim can be a challenging process – especially if you’re not well and you were expecting to be reimbursed.
But with the right approach and support, you can increase your chances of a successful outcome.
