Insurance plans are great at denying claims, but not so great at explaining why.

However, did you know that a federal law says that your client has the legal right to see the health plan’s case notes about the claim denial, including their internal correspondence, telephone logs, call summaries, and call recordings? It’s all in the claim file, which your client has the legal right to ask for, and to receive within 30 days of the request.

This information could help you and your client to fight the denial.

Requesting the claim file

ProPublica, an independent, nonprofit investigative journalism organization, has designed a tool that makes it easy to request a file. The tool, called Claim File Helper, can quickly generate a letter to send to any health plan to request a claim file.

Maya Miller of ProPublica reports that more than 1,000 people have used the tool already, and clients have won appeals by using the information they received from this request. In fact, Miller says some people’s denials were overturned just by submitting the claim file request, perhaps since the insurance company thought it was an appeal.

My test drive

I test-drove Claim File Helper today, inputting details from a fake claim denial letter. I found that it is designed to create a letter to the health plan from a client, not a therapist. But that doesn’t matter. If you are a therapist, you can ask the client to sign the generated request for their claim file in order to help you appeal a denial. Or if your client has been denied reimbursement, they can use this tool to help them dispute the denial.

I found Claim File Helper quick and easy to use. Minutes after inputting information from the denial letter, it had created a very official-looking letter to the health plan requesting a client’s claim file. Then it gave detailed instructions on what to do once you have the letter.

While the tool states it can work for employer-sponsored private insurance plans as well as plans purchased from your state and Medicaid plans, the tool did state that ProPublica is unsure whether Medicare enrollees are allowed to request a claim file.

Worth a try

Miller admits she has heard from people who never received their file after submitting the request. But I would urge you to give it a try, especially since – unlike most insurance paperwork – it is pretty easy and quick.

It may give you and your client some nuggets of information that will be the key to helping you win an appeal, to get the money you (or your client) deserve. And while they aren’t attorneys, the folks at ProPublica may even give you advice on what has worked for others to get denials overturned.

If you do submit a request (and this part is totally up to you), you can also help Miller and her colleagues at ProPublica to improve the tool, and assist them with their investigations about insurance denials, and what can be done.

Want a deeper dive?

• Find out more about how it works and/or submit your Claim File Request at Claim File Helper
• Read past ProPublica stories on requesting claim files:
• A story prior to their development of the Claim File Helper
• A follow-up story launching Claim File Helper
• Sign up for ProPublica’s newsletter of investigative journalism, often about healthcare abuses

READ MY FOLLOW-UP ARTICLE ON THIS TOPIC, giving denial stats for different insurance plans, most common reasons for denials, and helpful tips on what you can do about them – click here