What Is Reconsideration
Reconsideration is an informal request asking your insurance company to review a denied or underpaid claim based on new information or a clerical error. It's faster and less formal than an internal appeal, but it's also not legally required under federal law, so insurers can deny reconsideration requests outright.
Reconsideration vs. Formal Appeals
The distinction matters because it affects your timeline and legal protections. Reconsideration is your first informal attempt to get the insurer to look again at their decision. If you submit additional medical records, lab results, or documentation showing the service met medical necessity criteria, you're essentially saying, "You missed something the first time."
A formal internal appeal, by contrast, is your legal right under the Affordable Care Act and state insurance laws. Insurers must respond to internal appeals within 30 days for urgent cases or 72 hours for expedited requests. Reconsideration has no such timeline requirement because it's not a formal process.
When to Request Reconsideration
Reconsideration works best in specific situations:
- Coding errors: The claim was denied because of an incorrect procedure code or diagnosis code that you can correct with supporting documentation.
- Missing documentation: Your prior authorization request was incomplete, or your physician's notes didn't clearly establish medical necessity on the first submission.
- Underpayment disputes: You believe the insurer applied the wrong fee schedule or miscalculated your out-of-pocket obligation on the EOB.
- Timing issue: Your claim was denied for arriving outside the filing deadline, and you have proof it was submitted on time.
How to Submit Reconsideration
Contact your insurer's claims department or appeals line directly. Many insurers list a reconsideration phone number on your EOB or denial letter. Submit your request in writing, ideally by certified mail or through your insurer's patient portal, so you have proof of submission. Include a brief explanation of why the original decision was wrong, attach copies of any new or missing documentation, and reference the claim number from your EOB.
State regulations vary. Some states, like California and New York, require insurers to formally document reconsideration requests, while others don't. Check your state insurance commissioner's website for local rules.
Common Questions
- Should I do reconsideration or go straight to a formal appeal? If you know you have missing documentation or a clear clerical error, reconsideration can resolve it in days instead of weeks. If the denial is based on a medical necessity dispute or policy interpretation, skip reconsideration and file a formal appeal, where you have legal protections.
- What if the insurer ignores my reconsideration request? If you don't hear back within 15-20 business days, follow up in writing and reference your original submission date. Then file a formal internal appeal to start the clock on their legally required 30-day response window.
- Can I lose appeal rights if I request reconsideration first? No. Reconsideration is a separate track and doesn't trigger the clock on your appeal deadline. Most plans give you 180 days from the denial date to file a formal appeal.