Appealing a Claim
Insurance is an employee benefit. When your insurance company doesn't honor your policy and you are required to pay more than your policy states to your healthcare provider, you are being denied your rightful benefits. In that case, you can file and appeal with your insurance. If they refuse to process your claim according to your policy, you can file a complaint with the State Insurance commissioner and ERISA, a federal agency created specifically to punish insurance companies that defraud their members.
If you're not satisfied with the allowed amount on your claims, you can start the appeal process by sending a written request to the address listed in your plan materials within 180 days of receipt of this explanation of benefits (unless a longer time frame is provided by applicable state law or permitted by your plan). Please follow the steps below to make sure that your appeal is processed in a timely manner.
Send a copy of the explanation of benefits along with any relevant additional information (e.g. benefit documents, medical records) that helps to determine if your claim is covered under the plan.
Include: 1) Your name
2) Account number if any on your explanation of benefits
3) ID number
4) Name of the patient
5) Name of Primary Subscriber
6) Write "Attention: Appeals Unit" on all supporting documents.
You can require your insurance company to send copies of all documents, records and other information about your claim, free of charge. You will be notified of the final decision in a timely manner, as described in your plan materials.
If your insurance is provided by an employer that isn't a church or government entity, it is governed by ERISA. You can file a complaint with ERISA for low paying or denied claims.
You can also visit the DOL's consumer assistance web page to file a complaint or ask questions about your health plan benefits.
EBSA's benefit advisors will pursue every complaint and attempt to resolve it informally. If the complaint is valid but cannot be resolved informally, it may be referred to enforcement staff for further review.
If you're not satisfied with the allowed amount on your claims, you can start the appeal process by sending a written request to the address listed in your plan materials within 180 days of receipt of this explanation of benefits (unless a longer time frame is provided by applicable state law or permitted by your plan). Please follow the steps below to make sure that your appeal is processed in a timely manner.
Send a copy of the explanation of benefits along with any relevant additional information (e.g. benefit documents, medical records) that helps to determine if your claim is covered under the plan.
Include: 1) Your name
2) Account number if any on your explanation of benefits
3) ID number
4) Name of the patient
5) Name of Primary Subscriber
6) Write "Attention: Appeals Unit" on all supporting documents.
You can require your insurance company to send copies of all documents, records and other information about your claim, free of charge. You will be notified of the final decision in a timely manner, as described in your plan materials.
If your insurance is provided by an employer that isn't a church or government entity, it is governed by ERISA. You can file a complaint with ERISA for low paying or denied claims.
- Complaints from Individuals. EBSA's Benefits Advisors generally handle inquiries and complaints from members of the public following procedures established by the Office of Outreach, Education and Assistance. When appropriate, Benefit Advisors may refer a participant complaint to the enforcement unit as an investigative lead for possible case opening. When a case is opened based upon a participant complaint, the assigned Investigator/Auditor will notify the participant of the complaint disposition. EBSA Investigator/Auditor should notify the participant quarterly on the progress of the investigation, and document final notification of the outcome in the case file.
- Call EBSA's toll-free number at (866) 444-3272
- Contact EBSA electronically at askebsa.dol.gov
You can also visit the DOL's consumer assistance web page to file a complaint or ask questions about your health plan benefits.
EBSA's benefit advisors will pursue every complaint and attempt to resolve it informally. If the complaint is valid but cannot be resolved informally, it may be referred to enforcement staff for further review.