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Insurance denial? Try calling human resources for help

If you’ve had a by your company, you’re not alone. According to a , private insurance plans sold through the (ACA) federal marketplace, or HealthCare.gov, denied about 20% of claims in 2023. But consumers rarely fought back: Less than 1% of those denied claims were appealed, according to the report.

While a claim denial may feel final, , a platform for medication savings, explains here that you have options. One place to start could be reaching out to your human resources (HR) department at work — especially if you have . Sometimes, someone in HR can advocate directly for getting a denied claim reviewed and reversed.

Key takeaways:

• If your health insurance denies a claim, your human resources (HR) department may be able to help. Employers with self-funded health plans may be more likely and able to reverse a denied claim.
• HR may also offer resources to help you fight a claim denial, such as claims assistance or legal assistance.
• If HR can’t help, you can appeal the decision yourself by gathering documentation to support your claim and filing it with your health insurance plan.

Does HR handle health insurance?

Whether HR handles health insurance issues at your workplace depends on how employee coverage is funded. Some employers who offer health insurance to their employees go with self-funded or self-insured plans instead of buying coverage. The employer hires a health insurance administrator to manage plan benefits and pays for claims. This means the employer makes the final decision about what is or isn’t covered by plans.

Many people don’t realize they can ask for and possibly receive employer help with a health insurance claim denial. If your employer offers , they can decide whether a service, supply, item, or prescription medication should be covered.

How can HR intervene if your insurance claim is denied?

If your insurer denies a claim, your company’s HR department may offer advocacy and/or . Employer help with insurance denials can come in many forms. But you may have access to options, such as:

• A claims advocate who can help you file an appeal.
• A step-by-step guide on how to appeal an insurance denial.
• HR support contacts for claims assistance.
• A resource library with templates for appeal letters and other documents.
• A referral to a specialized benefits attorney, whose services may be covered by the company.
• Legal plan benefits that may cover insurance claim denial appeals.

If you have a health plan that is funded by your employer, you may be able to make directly to the decision-maker.

For example, let’s say you were denied coverage after a prior authorization process determined a procedure was not medically necessary. You could approach your company’s HR department with documentation from your physician about the medical necessity of the procedure, offering details that may have been overlooked. There’s no guarantee that your employer will agree to pay the bill, but it’s always worth asking. Denied claims may be reversed in part or in full — and sometimes even beyond what’s requested.

When HR cannot help with denials

If your employer-based plan is not self-funded, you may not be able to get the type of insurance denial help from HR described above. But even if you can’t appeal a claim denial internally, HR may be able to provide as you go through the process.

Some companies offer knowledgeable advocates or underwrite legal services that can help you fight an insurance denial, so it’s worth checking to see what’s available. HR may also offer tools such as appeal letter templates and step-by-step instructions for challenging a denied claim.

What else can you do if your insurance claim is denied?

If your and you can’t get help from HR, don’t panic. The first step is to determine why you were turned down for coverage. Review the (EOB) you should have received from your insurer regarding the reason for your denied claim.

Make note of how to challenge your denial as outlined in the EOB, as well as the appeal submission timeline. Typically, you have from the date of the EOB to file an appeal.

It’s also important to review your health plan’s , which explains what is covered and outlines any plan restrictions or limitations. This may help you further understand .

If the denial involves a , talk to your prescriber about an affordable alternative — such as a generic version, a , or another medication altogether. You can also consider to cover the medication based on a . Some manufacturers also offer and , which can significantly reduce your out-of-pocket costs if you qualify.

If the denial involves something other than a prescription medication, review your EOB for details about . Also, reach out to the medical practice or hospital that filed the claim to see if they can:

• Correct any errors, which you’ll typically need to identify.
• Resubmit the claim.

Gathering and submitting documentation

You may also need a member of your medical team to produce a and other records to support your appeal.

Once you’ve gathered the required documentation, write an to support your case. Submit the documents along with a completed appeal form, if needed, to your insurance company. Make copies of all documents you submit, which should be sent with delivery tracking if you’re using mail. Verify your appeal was received by contacting your health plan and follow up to ensure that your submission was adequate. Ask for the estimated date for a response and stay in contact with your insurance plan.

If a prior authorization claim was denied, expect to within 30 days of your plan receiving the documents. If you’re appealing a claim for a service you have already received, a response can take up to 60 days. If your appeal is denied, you can then request an , or an , as another avenue to get your claim approved.

Frequently asked questions

Why do health insurance companies deny claims?

There are many reasons why health insurance companies . A claim may be denied because of data entry or medical coding errors, missing documentation, a duplicate claim, or a missed filing deadline. Or it’s possible you’ve exhausted your benefits or failed to get the required prior authorization. Alternatively, a service or item may not be included in your benefits or coverage network, or it may not be deemed medically necessary by your plan.

How often do insurance companies deny claims?

According to a , health insurance plans purchased through HealthCare.gov denied 1 in 5 claims, or 20% overall, in 2023. Claim denial rates differed by insurance company but could exceed 50% for in-network claims, depending on the health plan and state.

Can your employer reimburse you for insurance denials?

Your employer cannot reimburse you for an insurance denial, but they may be able to approve your claim depending on how your health plan is funded. Some employers offer self-funded or self-insured health plans, which means they shoulder the costs of medical care for their employees but pay a third-party health administrator to handle benefits. If your employer offers self-funded plans, you may be able to appeal a claim denial through your company’s HR department.

The bottom line

If your medical claim is denied, try contacting your company’s human resources (HR) department to see if someone there can help reverse the decision. If your employer-based health plan is self-funded or self-insured, your company may agree to pay your claim.

If that’s not an option, gather supporting documentation and file an appeal with the insurance company. Even if the appeal is denied, you can file a second appeal to be handled externally. Your HR department may offer claims assistance, legal support, or other resources to help you overturn a health insurance claim denial, even if they can’t help you appeal directly.

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