What Is a Claim
A claim is a formal bill submitted to your insurance company requesting payment for healthcare services you received. Your provider's office typically files this on your behalf, though you can file one yourself if the provider doesn't. The claim includes details like the service date, procedure codes, diagnosis codes, the amount charged, and your policy information.
How Claims Are Processed
When your provider submits a claim, your insurer has 30 days under most state regulations to acknowledge receipt and begin processing. They review whether the service meets your plan's coverage rules, whether it was medically necessary, and whether prior authorization was obtained if required. Your insurer then sends you an Explanation of Benefits (EOB) showing what they approved, what they denied, and what you owe.
A Clean Claim (one with complete, accurate information) typically processes within 30 to 45 days. Claims missing information get returned for corrections, which resets the processing timeline.
Prior Authorization and Claims
Some services require prior authorization before you receive care. If your provider didn't obtain it and you received the service anyway, your insurer may deny the claim even if the service was medically necessary. This is why confirming authorization status before treatment matters. When prior authorization is denied, you still have appeal rights.
Your Claim Appeal Rights
If your claim is denied, you can file an internal appeal with your insurance company. Most insurers have 72 hours to acknowledge your appeal and 30 days to issue a decision. If the internal appeal fails, you have the right to file an external appeal with your state's insurance commissioner or an independent review organization. External reviews are free in most states and often overturn internal denials when medical necessity is documented.
Medical Necessity Standards
Insurers frequently deny claims citing lack of medical necessity. Your doctor's clinical notes and treatment plan become critical evidence in appeals. Medical necessity varies by state, but generally means the service was appropriate for your diagnosis, followed standard medical practice, and was not experimental. Your appeal should reference specific clinical evidence supporting why the denied service was necessary for your condition.
Common Questions
- How long do I have to appeal a denied claim? Most states allow 60 to 180 days from the denial date, but check your EOB or plan documents for your specific timeframe. Don't delay, as deadlines vary by state and insurer.
- Can I appeal if my provider didn't file the claim correctly? Yes. Request the claim be resubmitted as a clean claim. If the provider refuses, you can file it yourself and appeal any resulting denial. Keep copies of all correspondence.
- What's the difference between an internal and external appeal? Internal appeals go back to your insurer's review team. External appeals go to an independent third party chosen by your state. External reviews are more likely to succeed if medical evidence supports your case.