Health Insurance Topics
Click any topic below for detailed guidance on handling your specific health insurance dispute.
Denied Medical Claims
Fighting Claim DenialsYour claim was denied. Learn why insurers deny claims, how to challenge denials, and what to include in your appeal.
- Common denial reasons
- Medical necessity disputes
- Documentation requirements
- Appeal deadlines
Prior Authorization Denials
Pre-Approval IssuesPrior authorization delays and denials can prevent you from getting needed care. Learn how to navigate and appeal these decisions.
- When prior auth is required
- Expedited review requests
- Peer-to-peer reviews
- Urgent care exceptions
Appeals Process
Internal & External AppealsEvery denied claim can be appealed. Understand the multi-level appeals process and how to maximize your chances of success.
- Internal appeal requirements
- External review rights
- Writing effective appeals
- Supporting documentation
ERISA vs. State Law
Employer Plan RulesIf you get insurance through work, ERISA may limit your rights. Understanding ERISA is critical before you appeal or sue.
- ERISA preemption explained
- Administrative exhaustion
- Limited remedies under ERISA
- When state law applies
ER & Surprise Billing
Emergency Care DisputesSurprise bills from emergency rooms and out-of-network providers are a major issue. Learn your rights under new federal protections.
- No Surprises Act protections
- Balance billing rules
- ER denial appeals
- Prudent layperson standard
Mental Health Parity
Equal Coverage RightsFederal law requires equal coverage for mental health and substance abuse treatment. Many insurers still violate these rules.
- Parity Act requirements
- Visit limit violations
- Prior auth disparities
- Residential treatment coverage
CA Independent Review
California IMR ProcessCalifornia offers a powerful Independent Medical Review (IMR) process that can overturn insurer denials - and it is free.
- When to use IMR
- Filing requirements
- Expedited IMR for urgent cases
- IMR success rates
Network Disputes
In vs. Out-of-NetworkDisputes over network status can lead to huge bills. Learn how to challenge out-of-network charges and network adequacy issues.
- Network adequacy standards
- Ghost network issues
- Continuity of care rights
- Out-of-network appeals
California Health Insurance Protections
CACalifornia provides some of the strongest health insurance consumer protections in the nation. Key California-specific rights include:
- Independent Medical Review (IMR): Free, binding external review of claim denials through the DMHC
- Timely Access: Insurers must ensure you can get appointments within specific timeframes (10 days for specialists, 48 hours for urgent care)
- AB 72: Protection against surprise billing from out-of-network providers at in-network facilities
- Mental Health Parity: Strong enforcement of mental health parity requirements
- Continuity of Care: Right to continue with providers who leave your network during active treatment
What You Need to Know About Health Insurance Disputes
- Every denial can be appealed: Do not accept a denial as final - you have the right to appeal
- Deadlines matter: Most appeals have strict filing deadlines (often 180 days from denial)
- ERISA limits your rights: Employer-sponsored plans are subject to ERISA, which limits damages and requires exhausting administrative appeals
- Get your claim file: You have the right to obtain a complete copy of your claim file from the insurer
- External review is powerful: After internal appeals, external review by independent reviewers often overturns denials
Understanding Health Insurance Claim Denials
Health insurers deny claims for many reasons, some legitimate and some questionable. Common denial reasons include:
- Not medically necessary: The insurer's reviewers determined the treatment was not needed (often incorrectly)
- Experimental or investigational: The insurer claims the treatment is not proven, even if your doctor disagrees
- Out of network: You received care from a provider not in your plan's network
- Prior authorization not obtained: You or your provider did not get pre-approval
- Service not covered: The specific treatment is excluded from your plan
- Coding errors: Administrative mistakes in how the claim was submitted
Many denials are overturned on appeal. Studies show that consumers who appeal health insurance denials succeed approximately 40-50% of the time. Do not give up just because you received a denial letter.
Related Insurance Resources
Need Help With Your Health Insurance Dispute?
If your health insurer has denied coverage for needed treatment, I can help. I draft appeal letters that cite the right regulations, challenge bad faith denials, and fight for the coverage you are entitled to under your policy.