About the Medical Insurance Appeal Process
Wondering how to appeal an insurance denial? A medical insurance appeal is a request by the patient or an authorized representative of the patient (such as PRIA Appeals) for a health insurance plan or payer to review and change a denial of coverage.
It does not involve lawsuits, judges, arbitration or lawyers. It is you, as the customer of the insurance company, asking them to change a specific decision that was not in your favor.
If you have been denied coverage and want to appeal the decision, here’s how the medical insurance appeal process works:
- Your provider submits a prior authorization request or a claim for payment for a medical procedure, either before or after it has been performed.
- You receive a denial from your insurance company, saying they will not cover or pay for the procedure.
- You contact PRIA Appeals, either on your own or after a referral from your provider.
- PRIA Appeals will conduct a free assessment of your denied case. We will collect information on your insurance company, policy, the procedure denied, your medical records and any other pertinent information.
- PRIA Appeals will determine whether an appeal is possible and likely to succeed in your case.
- If we determine that an appeal is possible and you want to go ahead with the process, you don’t have to do anything else! PRIA Appeals will work on your behalf directly with the insurance company.
- We will stay in very close contact with you throughout the appeal process, which usually takes 30-90 days.
- When the issue has been resolved, we will immediately contact you to let you know the outcome.
- If your appeal is successful, you can immediately contact your medical provider to schedule your surgery or treatment. If your appeal was for a past procedure, we will work with you to ensure you receive payment.