Get the facts: Why did I get a letter from my insurance company, and what does it mean?

• Federal and state regulations require insurance companies to send formal notification letters to members throughout the process of reviewing their claims, even before the final decision has been reached.
• It’s important to know that what might look like a denial letter could actually signal that your claim is still moving through your insurer’s review process and could ultimately end up being approved.
• If you receive one of these letters, start by giving it a thorough review, and call the number on the back of your health plan ID card if you have any questions.
• If your claim isn’t approved, you have the right to file an appeal.

If you’ve ever found yourself standing in your kitchen, reading and re-reading a letter from your health insurer, and struggling to figure out what exactly it means, this article is for you. And if that letter sounds suspiciously like your claim wasn’t approved, it’s understandable if your confusion soon turns into frustration or worry about whether your provider will be sending you a bill.

For many people, letters like this don’t just raise questions — they can create stress at an already vulnerable moment, when you’re focused on your health or caring for a loved one.

Read on to learn more about why you received the letter, why it doesn’t necessarily mean your claim won’t be paid, and why your best next step might be to simply wait for your insurance company and provider to resolve the claim on your behalf.

First of all, don’t panic. It’s important to know that this type of letter is not necessarily the end of the story, and there are two main reasons for that:

• The letter could signal that your claim is still moving through the insurer’s review process, and once that process is completed, it could end up being approved and paid. 
• Even if your claim isn’t ultimately approved, you still have the right to file an appeal.
   

While the vast majority of claims move through the review and payment process swiftly, some require a more extended review that can delay the final decision as to whether the claim will be approved. For example, more information might be needed from the doctor about the services provided or the timing of those services.

Health insurers are among the most regulated entities in the country. Federal and state regulations require insurance companies to send formal notification letters to members throughout the process of reviewing their claims, even before the final decision has been reached. And those same regulations stipulate what information must be included in the notification letters.

The regulations were intended to ensure that health insurers are transparent with members about the status of their claims, but the required text in the letters can unfortunately leave people confused or under the impression that their claim has officially been denied when in reality, it’s simply undergoing further review. 

So if you receive what appears to be a denial letter, the first step you should take is to give it a thorough review.

• Look for language that suggests the insurer is seeking additional documentation so the claim can be reconsidered. If you see that type of language, your doctor’s office should have received a similar letter from your health plan notifying them of the need to send additional information.
• The instructions for next steps can also be useful to assess where your claim is in your insurer’s review process.
• You can also call your health insurance company and ask a member services representative to explain the status of your claim.
• Alternatively, check if your insurer offers real-time claim updates in its mobile app. If so, that can be a great resource to find more up-to-date information and answers to questions.

The timing of when you receive the letter is a good indicator of what the letter’s purpose is.

Healthcare providers submit claims to insurance companies after care has been delivered. So if you get a letter after you’ve received care or completed your treatment, it’s most likely about the processing of your claim.

If you get a letter in advance of a surgery or procedure or before you start taking a new drug, it’s most likely because that service or medication requires prior authorization. Check out this article to learn more about the purpose of prior authorization.  

We agree — it should be better. Health insurers are required to follow federal and state regulations that dictate not only when letters about the status of claims must be sent to members but also the information to be included in those letters.

• The regulations are incredibly specific, covering everything from the wording of the greeting to the font size of the disclaimers included at the end of the letter.
• Those regulations offer insurers very little flexibility to customize letters to reflect the member’s specific situation.
   

That being said, at UnitedHealthcare, we know the letters can feel impersonal and difficult to understand, so when people have a negative reaction to them, we get it. Nothing is more personal than healthcare, which is why we work hard to treat our members with care and sensitivity when they call our member services department with questions about a claim denial. Unfortunately, the way we communicate with our members through letters today comes up short, lacking the clarity, empathy, compassion and personalization that our members should expect from us.

We know we can do better, which is why we have teams dedicated to the work of re-examining our approach to how we communicate with our members about the status of their claims. Those teams are actively working to make the letters clearer, more helpful and more human — simplifying language, testing different formats, and identifying ways to make the letters easier to understand while still meeting regulatory requirements. These improvements should help you more quickly know what’s happening and what to do next.

We’re also investing in digital claim tracking tools and real-time support through member services to help people get clearer, faster answers without having to wait for a letter.

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