Most people with health insurance have never encountered problems submitting claims to their insurer. However, your health insurance plan may still deny a claim at some point. What should you do if your insurance company denies a health care claim that you know it should cover? You should appeal the denial. There are two types of appeals, internal and external. When making an internal appeal, you, as the consumer, work directly with your insurance provider to appeal the decision. With an external appeal, you work with your state insurance commission to fight the denial of your claim. However, when is the time to engage your state insurance commission in making your appeal?

If your health insurance plan has denied coverage of a claim that you believe should be covered, you should first appeal the decision directly to your insurance provider. Often, you can address the reason for the denial with the insurer relatively quickly. Insurance companies may deny coverage for something as simple as missing information or incorrect codes submitted by your physician. In cases such as these, you can often work directly with your insurance company and physicians to submit the correct information and reverse the original decision to deny coverage.

However, sometimes internal appeals are not sufficient to reverse a denial of coverage. If you have attempted to work with your insurance company directly and the company is still denying coverage that you believe your health insurance plan should cover, it may be time to contact your state insurance commission and begin the process of external appeal.

If you have exhausted all internal channels of appealing your health insurance denial, it is time to call the state insurance commission. Every state is different and has a different process by which health insurance appeals are reviewed and decided. For this reason, it is important to contact your state insurance commission directly and speak with a knowledgeable employee about the specifics of your state's appeal process. Most states will allow you to make an appeal directly to an independent board that will make a decision about your claim denial. If the board agrees with your appeal, your insurer is forced to reverse its decision.

It is important to remember that not all health insurance plans are subject to the state laws where they operate. Your state insurance commission will be able to confirm that your health insurance plan is governed by your state commission.

If you have been denied coverage and are appealing the decision, whether through internal or external processes, it is important to keep detailed records of every communication and send all written communication by certified mail or some other verifiable delivery process.