If you're like most people, when your health insurance denies your claim, you feel frustrated and helpless. After all, if your health insurance says you don't need care but you do, you can either appeal the decision or pay for the care yourself.
Most claims are turned down for particular reasons. If your health plan denies your claim, the most likely reason is that there isn't enough information. You can make sure this is true before filing an appeal by making sure that all pre-authorization requests were filled out with correct patient information.
For instance, is your social security number written down correctly? Does the doctor have the most up-to-date copy of the card for your health plan? Does your doctor have the most up-to-date list of diagnosis and procedure codes so that he or she can fill out the forms correctly?
By making sure that you sent the right paperwork to the doctor and that the doctor sent the right paperwork to the health plan, you are ready for the next step. When you deal with your health insurance company, you should be suspicious.
Write down every phone call, person you talk to, and piece of information you get. One mistake in communication is all it takes to cause a problem. By writing down everything you say to the insurance company, you are preparing for any appeals case.
If you have a claim for treatment coverage that you want to appeal, make sure you've read the appeals process in the health insurance handbook for your company. Most patients don't read the manuals that their insurance company gives them. In these handbooks, you can find information about plan requirements and how to file an appeal. If possible, you should make sure that your plan covers any treatment you are going to get before you get the treatment.
When you need to file an appeal
Every plan should have a clear way to make an appeal, and you should follow it. If you want to appeal the claim, you should talk to your doctor about it so they can help you with the paperwork and expertise you need. Remember that most insurance claims can only be appealed within a certain amount of time. If your claim was denied and you waited six weeks to appeal, and you only had 60 days to do so, you may already be out of time.
You should always go to your insurance company first before going to a government or state appeals process or another outside source. The process for most appeals goes like this:
- Complaint in Writing
- Request in Writing
- Phone Complaint
In this area, too, you should be very clear about the rules of your plan's coverage and keep track of every time you talk to the insurance company. Even though most valid appeals are accepted by the insurance company, there have been cases of insurance fraud and health plans that don't follow the rules. By keeping track of response times and any required response times, a patient can use up all of their options for a valid appeal against the insurance company and then take it to the next level.
In many states, there are laws that say how to appeal to a state or federal insurance oversight process. These laws often let an outside expert look at the appeal. By giving accurate paperwork and detailed medical evidence from your physical, a board of qualified experts can then decide your case on an individual basis. If an outside appeal proves the claim is valid and overturns the denial, your insurance company won't be able to turn down the claim.
The best ways to get the treatment you need approved are to know your health plan, talk to your doctor about procedures, and look into the appeals process in depth. Don't forget the little things, keep accurate records, and look over your coverage plans if you have questions. Keep in mind that there are always choices.
