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How Do I Appeal Claims Adjudication?

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  • Written By: Lainie Petersen
  • Edited By: Melissa Wiley
  • Last Modified Date: 04 September 2016
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    Conjecture Corporation
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To appeal claims adjudication, you should first contact the insurance company or government agency that is denying your claim and request detailed information on its adjudication process. After you have information on what you will need to do to appeal claims adjudication, you should then seek out expert advise from a lawyer or experienced third-party advocate who can assist you in preparing your case or representing you at a hearing. It is also crucial that you participate in the appeals process fully by gathering important documentation and providing it to your lawyer, advocate, or the appropriate officials during your appeal.

The process to appeal claims adjudication varies by organization. If your claim has been denied, you may be automatically provided with a letter that explains your rights to appeal. Pay close attention to any deadlines listed in this letter. You may have a very limited period of time in which to get the appeals process going. If you don’t file an appeal by this deadline, you may permanently lose your right to challenge the denial of your claim. If you have difficulty understanding the process, contact the organization and ask for clarification or seek out assistance through an attorney or advocate.

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Depending on where you live and the type of claim that you have filed, you may be entitled to free or low-cost help when you appeal claims adjudication. For example, in the United States, some state unemployment agencies provide both employers and employees with free legal assistance with their appeals. You may also be able to get assistance through a legal aid society or a patient advocate organization. If the claim amount is significant and you can’t get free help, you may wish to consider hiring a lawyer who is an expert in dealing with claims adjudication.

After talking to a lawyer or advocate and reviewing the appeals process, begin assembling your documentation. You may be provided with a list of documents that you should obtain to assist you in your appeal. If you can’t find these documents, ask your legal adviser or advocate for advice on the best way to find them. Make copies of these documents and keep the originals in a safe place. Organize these documents so that they make more sense when you present them to your lawyer or a claims adjudicator.

You may be asked to participate in a telephone hearing or you may have to physically attend an appeals hearing. Alternatively, you may also be interviewed as part of the appeals process. Before attending a hearing or allowing yourself to be interviewed, speak to your legal adviser for information on what you should say during the hearing or interview. Keep in mind that both you and the insurer may have several opportunities to appeal a decision. While this could drag your appeal of claims adjudication out for some time, it also protects your interests by ensuring that you have ample opportunity to prove that you are entitled to benefits.

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