What options do we have for appealing the insurance company’s decision to deny a claim for my loved one’s care?

Allison Moskowitz Duggan, oncology social worker at CancerCare in New York City

It is not uncommon for people undergoing cancer treatment to receive a denial from their health insurance plan. These denials may be the result of a simple administrative error, a missing form, incomplete information or an overlapping claim. The good news is people who appeal denials are later approved at least half of the time. So, when you learn of a denial, take a deep breath and try not to panic.

Call your health care provider’s office and speak with the finance department. In many cases, claims are denied due to an error when they were submitted. Ask the provider’s office to check whether there could be an error that may require them to reprocess the claim.

Your next call should be to your insurance company. Insurers have to provide a reason for any denial of a claim. Some claims may be denied if they are for a treatment that is deemed not medically appropriate or is excluded from the coverage plan. You can file an internal appeal to correct any errors or provide information from your doctor documenting why the service is medically necessary. Your insurance company is required to provide guidelines for filing an appeal and should be able to tell you how long the process may take. If it’s urgent, you may ask to speed up the process. Keep records of all the information you gather along the way, including names and dates associated with any calls or other communication. Stay in touch with your care team in case the appeals process delays your loved one’s ongoing treatment and so they can assist with any needed documentation.

If your insurance plan still denies coverage for the claim after the internal appeal, you may ask for an external review by an independent medical professional. Denials can go to an external review if your provider disagrees with the health insurance plan’s decision or there’s a question about whether the treatment is necessary or experimental. The rules will vary depending on the state you live in, but typically you’ll have to request an external review in writing.

If you’ve exhausted all appeals, ask your health care team about other treatments that would be covered by your insurance, or explore options for financial assistance through your care center, pharmaceutical companies or nonprofit organizations.

While exploring your options, acknowledge the emotional impact this can have on you as a caregiver. The appeals process, while worthwhile to pursue, adds an extra layer of stress. Give yourself grace as you work through the process and learn as you go. If you feel overwhelmed managing your loved one’s day-to-day needs, look for others in your support system who can help you with these essential tasks.

FILING AN INSURANCE APPEAL // Healthcare.gov offers an overview of how to appeal an insurance company decision. // Triage Cancer has a printable health insurance appeal tracking form to help you document the whole process.

The expert’s response was edited for clarity and based on an interview with Kendall K. Morgan.