If you have undergone medical treatment and your insurer is refusing to pay out it can be a very worrying and stressful time. However, there are steps that you can take to reverse your insurer’s decision.
First, start by checking your policy documents carefully and find out what is, and what isn’t covered. This document should also detail any exclusions and limitations set by your insurer. When you have read this document thoroughly then take a look at the letter that your insurer sent to you when they denied your claim. This letter should also provide you with information on how to appeal.
If you are unsure why your claim was denied then get in touch with your insurance provider and ask them. If you feel that they have made a mistake then ask them to send you further information with regard to their appeal’s process. Make sure that you keep a note of the date, who you spoke to, and what was said. Your insurer may tell you that your claim was denied because your doctor failed to use the correct code, or omitted vital information. If this is the case then get in touch with your doctor’s office and ask that they re-send the paperwork.
If your health insurance is part of your employee benefits package then talk to your HR department. They may be able to intervene and persuade your insurer to uphold your claim.
If your insurer is still refusing to pay out after you have spoken to them then by law you are within your rights to appeal; both with your insurer, and via an external review from an independent third party. It is important that you follow your insurer’s appeals process, and to submit your claim before the deadline if one exists. At this stage you will need to inform your doctor, or the hospital in which you received treatment, and ask them to delay sending out any bills until your complaint is dealt with. Try to ensure that they do not send your account to a collections agency as this will have a seriously detrimental effect on your credit rating.
If your claim was denied for treatment that has already been carried out, or for treatment that your doctor has advised then ask your doctor’s office to write to the insurance company explaining why you needed, or are in need of, the treatment. This letter should be sent to the address stipulated in your plan’s appeals process. Keep a copy of this letter.
Your appeal will begin with an internal review, and this will start when you file your official complaint. Personnel from your insurance company who were not involved initially with your claim will be asked to examine your case. You can ask that they do this as a matter of urgency if you require immediate medical attention; they will then be asked to make a decision within seventy-two hours. When your insurer has investigated your case they will then contact you with their decision. If they decide to reverse their decision not to pay out then your healthcare costs will be covered. However, they may decide to uphold their original decision to deny your claim. If this is the case then you can still take matters further by asking for an external appeal.
You need to request an external appeal usually within four months of your claim being denied. An independent, third party will then carry out their own review. If you are not well then you can ask for an external review before the internal review is carried out. You can also request that the review is expedited if you are in need of a quick decision due to poor health; this must be carried out by the independent review body within seventy-two hours. However, bear in mind that some insurers will conduct more than one internal review before you are entitled to request the help of an external review panel.
If you need help filing your appeal you can contact a Consumer Assistance Program if your state has one. If your health insurance is part of your employee benefits package then you can also ask for help from your employer’s human resources or benefits department. They will help by guiding you through the process, and answering any questions you may have.
If you do have a claim denied then it is important that you learn from the experience and take measures to stop the same problem from reoccurring. Prior to obtaining treatment find out what is, and what isn’t covered by your health insurance plan, and follow the plan’s guidelines carefully. For example, some insurers may require pre-authorisation. In addition, some plans have certain limits on the benefits that they offer; you may only be allowed a certain number of home health visits in one year for instance. Finally, make sure that your healthcare provider of choice in part of your plan’s network. Terms and conditions vary widely between providers, but some plans will not pay towards care given by providers that are not included in your health plan.
Having a health insurance claim denied can be a worrying time, but there are plenty of measures that you can take to rectify the problem. You can also avoid claims being denied in future by carefully reading the terms and conditions of your plan and adhering to them closely.