My claim was denied for a billing or coding error. What do I do?

Why was my claim denied for a coding or billing error?

Every claim is a form filled out by your provider's office. If a code, a date, a name, or a number is wrong or missing, the insurer can deny it even though the care itself may be covered. If you opened the letter and felt lost, you are not alone.

Your denial letter or Explanation of Benefits should say why the claim was denied. Insurers have to tell you why they denied a claim and how you can dispute the decision.

How do I ask the doctor's or dentist's office to fix the mistake and resubmit?

Start with a calm phone call, then follow up in writing so you have a record. A polite, specific request usually works best.

• Step 1: Read the denial. Find the reason and any code or note the insurer lists on the denial letter or Explanation of Benefits.
• Step 2: Call the office. Ask for billing, say the claim was denied for a possible coding or billing error, and ask them to review it and send a corrected claim.
• Step 3: Write it down. Note the date, time, the person's name and title, and what was agreed. Send a short message or email repeating the request.
• Step 4: Check back. Ask the insurer whether the corrected claim arrived. If you hear nothing, follow up again and keep your notes.

What if the office will not fix it or does not answer?

You still have options. You can file an internal appeal with your insurance company yourself and ask them to review the denial. Include your name, claim number, and insurance ID number, a copy of the denial notice or Explanation of Benefits, your notes from calls, and any letter that supports your case, such as one from your doctor.

If the insurer still says no, some denials can go to an independent outside reviewer, and the insurer is required by law to accept that reviewer's decision. External review mainly covers denials based on medical judgment, treatment called experimental, or a cancelled policy, so a pure paperwork denial may not qualify. Your insurer's final letter should say whether you can ask for one.

How long do I have to appeal a denied claim?

Under the rules HealthCare.gov describes for health plans, you must file an internal appeal within 180 days (6 months) of receiving the denial notice. Do not wait. Mark the date on your calendar the day the letter arrives.

If your denial can go to an outside review, you generally have 4 months from your insurer's notice or final decision to request it. Deadlines can differ by plan type, including Medicare, Medicaid, job-based plans, and dental plans, so the deadline printed on your own letter is the one to follow.

Who decides my appeal, and how long does it take?

For an internal appeal, your insurance company reviews its own decision. It must finish within 30 days for care you have not received yet, or 60 days for care you already received. Urgent cases must be decided as quickly as your condition requires.

For an external review, an independent third party looks at the case, so the insurance company no longer gets the final say. A standard external review is decided no later than 45 days after the request is received.

I have Medicare. Is it different?

Yes. Medicare has its own appeal process. Generally there are 5 levels, and if you disagree with a decision you can usually move to the next level. Each decision letter tells you how to take the next step. You can appeal if Medicare or your plan refuses to pay for something you already got, or refuses to change the amount you must pay.

Free help is available from your State Health Insurance Assistance Program (SHIP), and you can appoint a trusted family member or friend as your representative to help you.

Your checklist

• Find the reason for denial on the letter or Explanation of Benefits
• Write down the date you received the denial and the appeal deadline printed on it
• Call the provider's billing office and ask for a corrected claim
• Log every call: date, time, name, title, what was said
• Ask your insurer whether the corrected claim was received
• If no fix, file an appeal with your insurer and keep copies
• Text a photo of the letter to (213) 606-6303 for a free read

A letter you can copy

[Your name] [Your address] [Date] [Insurance company name] [Appeals address] Re: Appeal of denied claim Member name: [name] Member ID: [ID number] Claim number: [claim number] Date of service: [date] Provider: [provider name] I am appealing the denial of this claim, which I received on [date received]. The denial notice gives the reason as [reason stated on the letter]. I believe this was a coding or billing error and not a decision that the care is excluded. I have asked [provider name] to review the claim and send a corrected claim. [They have / have not yet] done so. I am asking you to review the claim again, and to process the corrected claim if one is sent. Enclosed: the denial notice or Explanation of Benefits, my notes from calls with the provider and with you, and [any supporting letter]. Please confirm in writing that you received this appeal and tell me the date of your decision. Sincerely, [Your name] [Phone number]

Which rules apply to you?

The steps and deadlines on this page can differ by the kind of plan you have. Your own denial letter always comes first.

• Coverage through a job:ask your HR team whether the plan is “self-funded” or “fully insured.” It can change who you can ask for help. Most private-sector job plans fall under a federal law called ERISA, and the U.S. Department of Labor’s EBSA takes health plan questions at Ask EBSA or 1-866-444-3272.
• Marketplace plan: follow the appeal steps at HealthCare.gov.
• Medicare or Medicaid: each has its own appeal process, listed on your notice.
• Dental-only plan: your plan contract sets the appeal rights, so read it and your letter.

Related answers

• Your claim was denied because you had no referral. Here is what you can do.
• Denied because the insurer says you have other insurance
• How to read an insurance denial letter
• How to write an insurance appeal letter
• All answers

Free tools for the next step

Keep your appeal papers in one place. Take a photo of your denial letter, EOBs and insurance cards with GetPreCare, so they are on your phone when the insurer or the office asks. Free. Open GetPreCare. Helping a parent or partner? Set it up for them.