In life, we learn quickly to expect the unexpected. That’s a big reason why we buy health insurance. But what if your policy doesn’t cover something you expected it to and you need to file an appeal?

The appeals process is there to make sure that coverage decisions are based on the facts – facts about your specific insurance policy, your claim and the current medical evidence and standards.

Understanding when to appeal

There are rare instances when a claim is declined due to an error, mistake or omission that could be on the part of the insurer, the doctor or the policyholder. Below are two examples that differentiate between a claim denial due to a mistake — which can be appealed — versus one denied because your health insurance plan does not include coverage for that particular service. Those denials are, generally speaking, not appealable.

You can appeal an incomplete claim

A request for a pre-authorization for a medical procedure may get declined, but not because your benefits don’t cover it. It may be because your doctor’s office inadvertently excluded a page or other piece of documentation when submitting the request. For some procedures, health insurers require information to establish “medical necessity” — records demonstrating that the test or procedure is appropriate and meets the standards of care established by the independent medical organizations that insurers rely on for their medical policy.

Out of policy

Insurance policies can be complicated. For instance, a service may be covered under some circumstances, but not others. For example, let’s say you have shoulder pain and go to a massage therapist because you know physical therapy is covered. While the massage is a covered benefit, it is likely only covered when the service is administered by a licensed physical therapist, but not when administered by a massage therapist. And therein lies the rub, so to speak. The claim denial should be appealed if the massage was administered by a physical therapist. If the massage was administered by a masseuse the appeal would not be approved.

Types of appeals

If a claim is denied for what a member or provider believes is missing information or a simple mistake, there are generally two appeal options: Administrative and Medical. It is important to know the distinctions. It’s also important to remember we wants to help you get the most out of your benefits and will help guide you through the appeals process. We know that it can be frustrating and we’re committed to working with you every step of the way until the situation is resolved.

Whether patient, doctor, specialist or insurer, all parties have rights and responsibilities in the insurance process. The appeals structure is a system of checks and balances that helps to ensure everyone is treated fairly, and the health care system is managed properly.


Cosmo Insurance Agency is an independent insurance agency serving surrounding communities in New Jersey. Cosmo keeps its promise to assure an efficient and creative approach to the services we offer. Each of our clients experience a personalized and long-term relationship with us. Our New Jersey based team of health brokers guides our clients in helping them choose the most cost-effective options. By incorporating the latest in technology-based tools and laws on healthcare, employee benefits, life insurance and finance, we keep our clients up-to-date with the plans that encompass all of their needs, whether it is individual or group insurance. 





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