|
|
Appeal an insurance claim How to get my health insurance claim paid? How to appeal my denied health insurance claim? In the event that an insurance company denies a medical claim from a doctor or hospital this does not mean the end of it. Health insurance claims are denied for many different reasons. It could simply be the doctor miscoded the bill and put the wrong medical billing code on the form, or a piece of information from the doctor was not submitted that needed to be, and many other reasons.
If you have gone for exploratory treatment or cosmetic treatment than most likely your bills will not be paid unless pre-authorized by the insurance company.
Pre-Authorization
The biggest way that an health insurance claim was denied is that the person did not receive “pre-authorization” for their treatment or surgery. Many health insurance companies and plans require that a insured call the health insurance company to receive prior authorization prior to getting treatment or a surgery. To ensure that your claims don’t get denied when you are going to the hospital or for surgery that is not an emergency, call your health insurance company beforehand to receive permission and make sure you follow any requirements or guidelines. The only exception to this pre-authorization rules is if you do have an emergency and do not have time to call the insurance company, then normal policy is that you should call within 24 hours of your admission to the hospital to let the insurance company know of the situation and your admittance to the hospital.
Why was my health insurance claim denied?If your health insurance claim is denied, you will get a Explanation of Benefits, commonly referred to as an “EOB” which explains what if any amounts the insurance company paid and for exactly what, and what if anything the health insurance company did not pay for and the reasons why they denied your claim. If you have not received your EOB, than call your health insurance company and request one.
Document Everything – Keep a Record of Everything
If you are dealing with a denied claim, then is it important for you to document everything. This means anyone you speak to at the insurance company, keep a record of what date and what time you spoke to your insurance company and exactly who you spoke to. If the employee at the insurance company cannot provide you with their name, you should be able to get an employee ID number.
Keeping the Doctor or Hospital in the loop.When your insurance carrier denies your claim, always keep your provider in the loop. This can help from the hospital or doctor sending your unpaid bill into collection and negatively affecting your credit rating. Call the doctor’s office or hospital and let them know you are appealing the insurance company’s denial of your claim and if they can please put a hold on your account until the appeals process is exhausted and over. Many doctors and hospitals will work with you in this process as they wish to get paid by the health insurance carrier.
Time Period for Appealing your claim denial
It is very important you read your benefits booklet and review your health insurance companies appeals process including the timeframe for making appeals. If your insurance company requires you to appeal your claim in 60 to 90 days, then they must receive your appeal in that timeframe. If you do not get your appeal in during the timeframe required by your health insurance carrier there is a high chance that your claim will be permanently denied. Also, keep track of your appeals process. Some health insurance companies can take weeks to review an appeal, some months. So, follow up directly with the insurance company and take notes on the progress.
Writing an Appeal Letter to your denied claim.
If your claim was denied, the first step after finding out why it was denied, is to write a letter appealing your claim and explaining why your claim should be paid by the health insurance company. One of the most important part of the appeals process is providing documentation that can show that the medical procedure you had was “medically necessary.” Some health insurance companies may deny your claim solely on the basis that they felt your medical procedure was NOT medically necessary. So, your doctor’s will probably be a good advocate and provide you more documentation and paperwork to prove that everything done to you was medically necessary. When you mail your letter to the insurance company, please make sure to do it in a way you can track it, such as certified mail or UPS or Fedex. This way you have documentation and confirmation the letter was received in the event the health insurance company later says they never received it.
My Appeal to the health insurance company was denied?
Even if your appeal was denied by your health insurance company this is not the end of the road. Many health insurance companies allow several appeals. So, even if you lose one or two appeals, you may win the third! Every time you appeal to try to include more information than before so that you are building a stronger case each time. If you lose the appeal process, then you still have one last option which is called “external review.” An external review is an appeal that you do directly to your State Department of Insurance asking them to review it. You can find more information on state’s external review appeal processes at www.kff.org/consumerguide/states.cfm .
Appealing a claim denial with a Self Funded Health Plan?
If your employer has a self funded health health plan and does not user a major health insurance company, than you cannot appeal to your State Department of Insurance as Self Funded health plans are exempted from State law and jurisdiction. In this event you must appeal under ERISA and do so to the department of Department of Labor's Pension and Welfare Benefits.
Stay Strong and Keep Fighting
Remember that no matter who upsetting it is to have your health insurance claim denied, that you should keep a positive attitude and continue fighting the denial. Work hard on getting a strong case, strong documentation and paperwork as to why it was denied and keep your communications with the insurance company professional and to the point. In a worse case scenario you also have the option of hiring an attorney that specializes in denied insurance claims and try this route. Depending on the cost of the medical claim, some insurance companies would rather settle than spend money on legal costs. |
|