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Can a denied health insurance claim be appealed?

Keep in mind...
  • It’s not uncommon for health insurance companies to deny claims due to pre-existing conditions
  • The best way to protect yourself against denied medical claims is to do your research prior to accepting health insurance coverage
  • Be diligent in keeping accurate records of all medical treatments and doctor visits

Health insurance companies sometimes deny claims for payment of services. When this happens, the amount of paperwork involved to correct the problem can be overwhelming. After all, if you pay for this insurance, should the company not have to pay for your claims?

Although people may end up paying for the services themselves, there are ways you can appeal the claim that’s been denied. In many cases, you will receive at least partial payment of the bills.

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Always Keep an Organized Paper Trail

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If your claim has been denied, the first thing you need to do is organize your paperwork. You may have received bills from providers, explanations of benefits, and letters from the company itself.

Put all of this together in one spot where you can easily access the information, and arrange it by date.  Collect any checks you’e used as payment for these services.

You should also ask your health care providers for copies of your medical records, which will document the course of your diagnosis and treatment.

Speak with your Health Insurance Company and Take Notes

Once you have all your paperwork in order, it is time to talk to the insurance company. Begin this process by contacting the customer service number found on your insurance card. Ask to speak to a claims representative, and let the representative know why you are calling.

You may be referred to a special representative who deals with claims appeals. Note the name of the person you talk to and the date of your conversation for future reference. Take notes on your conversation, so that you can refer to them if necessary.

Request Documentation in Writing

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If the customer service representative continues to support the denial of your claim, ask for the supporting documentation the company will use to justify the denial. This information can be mailed or faxed to you.

Note the date you spoke to the person and asked for the documentation so that you can know when you should reasonably expect to receive it. Once you receive the paperwork, take it to your doctor to see what he or she says about the validity of the denial.

What happens next depends on how your insurance is structured. If the company you work for is self-insured, you will probably want to talk to your benefits coordinator at work for advice.

If your company has a human resources department, you should reach out to them for guidance. If all else fails, you can file an appeal yourself. The length of time you have to file an appeal varies, but in most cases, it’s 180 days from the denial of services.

Some States have Review Boards

Some states have instituted independent review boards in which you can forward a denied claim for review. If you do so within 120 days, the insurer must pay for the review and defend the denial of the claim or pay the benefits.

To find out if your state has such a review board, contact your state’s Insurance Commissioner.

Should I pay the bills?

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Healthcare providers can sue if you do not pay, so it is a good idea to at least make minimum payment arrangements while your appeal is ongoing.

Most healthcare providers are able to provide you with a structured payment plan, which allows you to pay a small amount each month. If your appeal is later granted, the company will have to refund the money you have paid to you.

In worst-case scenarios, you may have to retain a lawyer, especially if the claim is for a large amount of money. If you do hire a lawyer, choose one who has a comprehensive understanding of insurance law. You can find such a lawyer from an online bar directory or by referral from another lawyer.

Your Responsibilities

The most important thing to remember is that you must prove that the insurance company should be paying the claim. It’s not uncommon for claims to be filed with incorrect numbers, so rectifying the problem is easy.

In other cases, insurance companies are justified in not paying a claim. For example, if a pre-existing condition was excluded at the time of service, your health insurance company has the right to deny the claim.

The only way to ensure that your claims aren’t denied is to fully understand your insurance benefits and any exclusions which may apply.

When you are offered health insurance from your workplace, or when you buy a policy yourself, take the time and read the literature.  Address any questions or concerns you have prior to accepting coverage from your chosen healthcare insurance provider.

Learn the ins and outs of health insurance before you sign on the dotted line! Use our FREE tool to compare health insurance quotes today!

 

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