Intimes of illness orinjury, the last thing youneedto worry about is your healthinsurancecoverage. Ifahealth claimhas beendenied, here are some tips to help you understandwhat you can do.
TOP CONSIDERATIONS
Whya claim getsdenied:In some cases, a simple error could be why your claim was denied. Your provider's billing staff may have entered an incorrect code, or your claim may have accidentally been sent to the wrong insurance company. This type of error can usually be cleared up quickly with a single phone call.But sometimes the reason can be more complex and require additional steps to get resolved.
Theappeals process:Your policy should indicatehow toappeal adenial. There are typically two levels of appeal:afirst-level internal appealadministered by the insurance companyand then asecond-level external review administered by an independent third-party.Your state insurance departmentwill be able to explain the appeals processin more detail.
Timelinesfor appeals:Generally,yourinsurance provider mustmakeadecisionregarding your internal appeal within the following timelines after receiving your request:
72 hours if you're appealing the denial of a claim for urgent care.
30 days for treatment that you haven't received yet.
60 days for treatment you have already received.
THINGS YOU SHOULD KNOW
Contact your insurance company:If you receive notice that your claim was denied, call your insurance company.You should find contact information on the back of your insurance card and the denial notice.Before you call:
Make a list.Have handyallthequestions you have about yourclaim’sdenialas well as the details of your treatment.
Gather all importantdocuments. This includes your policy,the Summary of Benefits Coverage(SBC),and your denial letter.
Keep notesof all conversations you have with company representatives.Make sure to note who you speak with, as well as the date and time youspoke. Ask for the person’s phone extension so you can contact them directly the next time youneed to call.
If yourinsurer continues to deny your claim, be persistent:The usual procedure for appealing a claim denial involves submitting a letter to your insurance company.Make sure to:
Give specific reasonswhy your claim should be paid under your policy.
Be as detailed as possiblewhen composing your letter.
Explain whyyour procedure or medication is necessary.
Include evidencethat supports your claim. This could include medical records like x-rays, lab results, or a letter from your physician that explains why your treatment is medically necessary.
Askto expedite the appealif you or your doctor feels that the denial of your claim could be life-threatening.
Keep copiesof everything you send to the insurance company for your records.
Contactyour state Department of Insurance if you feel your insurer is not cooperating with the appeals process.
TOP THREE THINGS TO REMEMBER
If a claim is denied, don’t panic. It could be a simple error that is easily fixed with a phone call.
When contacting your insurance provider about the denial, make a list of questions and gather all important documents beforehand. Keep detailed notes including the name, title and phone number of the person you spoke with.
When appealing the claim be persistent. Send your insurance company a note, being as specific as possible about why your claim should be paid and including as much evidence as you can to support your argument.
About the National Association of Insurance Commissioners
As part of our state-based system of insurance regulation in the United States, the National Association of Insurance Commissioners (NAIC) provides expertise, data, and analysis for insurance commissioners to effectively regulate the industry and protect consumers. The U.S. standard-setting organization is governed by the chief insurance regulators from the 50 states, the District of Columbia and five U.S. territories. Through the NAIC, state insurance regulators establish standards and best practices, conduct peer reviews, and coordinate regulatory oversight. NAIC staff supports these efforts and represents the collective views of state regulators domestically and internationally.
If you've received a denial, you have the option to submit it again. Depending on the denial reason, you may only need to resubmit the claim with any corrected fields.
Understanding the reason for denial is the first step towards resolving it. Correct Errors: Once the reason for denial is understood, the necessary corrections should be made to the claim.
There are a wide range of reasons for claim denials and prior authorization denials. Some are due to errors, some are due to coverage issues, and some are due to a failure to follow the steps required by the health plan, such as prior authorization or step therapy.
Companies will refuse to approve your request for compensation if your claim lacks support and evidence. The insurer may justify its denial by claiming that it believes your injuries were pre-existing at the time of the accident or that your own conduct made the injuries worse.
Whether or not you can bill a patient after an insurer denies a claim depends on a variety of factors, the first being whether you're providing emergency care or you're an out-of-network provider offering care at an in-network facility.
If your insurer continues to deny your claim, be persistent: The usual procedure for appealing a claim denial involves submitting a letter to your insurance company. Make sure to: Give specific reasons why your claim should be paid under your policy. Be as detailed as possible when composing your letter.
Ask to expedite the appeal if you or your doctor feels that the denial of your claim could be life-threatening. Keep copies of everything you send to the insurance company for your records. Contact your state Department of Insurance if you feel your insurer is not cooperating with the appeals process.
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