Health Insurance Claim Denied: What to do Next? Author:    Posted under: Health InsuranceHealth Insurance questions answered

Denial of health insurance claims can be defined by a number of reasons. Some of which can be as simple as not having the proper documentations or missing data, to billing and coding error, while others may find themselves in a much more complicated predicament. There are a lot of places that you can read on to prepare you for something like this. If you are reading this however, then chances are you have the same problem a lot of people nowadays have which is getting denied a health insurance claim.

Don’t fret! Knowing that many people share this experience and that there are still other things that you can do should come as good news. Sadly, a lot of people make the biggest mistake of just accepting or giving up whenever they come across an ordeal such as this. However, studies have shown that in a particular year, HMO in places like New York has upturned as much as of 43% of their denied claims and 17% of commercial insurers decisions were reversed following an appeal. Furthermore, 44% was won by those who appealed the second time and 45% for those who appealed the third time. So there is still hope as the chances are more and more on your favor. Remember that denying insurance claims happens a lot because this is how the companies save money, even if you’re claims are legit, so do not easily back down.

Here are some tips on what to do when denied a claim:

Always demand a written explanation or statement of the precise medical and scientific reason for denial; including a statement that identifies the policy condition that excludes treatment. If needed ask for the alternative treatments or services that are covered. Remember that Insurance companies are required by most state laws to provide written explanations of claim denials. Not complying to do this may constitute an illegal practice by the insurer.

Ask for instructions on how to initiate appeals of denials internally. This includes specific information such as whether it has to be in writing, your time limits (if there are any), the proper filing process including schedules and even contact numbers of key persons. You may also ask for instructions for filing an external request for review should the denial be upheld in the internal review.

Keep a good track record of every single information that you may need later on, including contacts, dates, and most of all paperwork. Keep everything concise especially your supporting documents that you may need to send to various people in order to either petition your claim or get help in doing so. One way is to start by writing a letter to the person who denied your claim and then work your way up. Include a copy of your relevant forms, your policy number, and any supporting documents that will help including a clear and detailed description of your problem. In many states, failure to answer promptly to letters regarding consumer claims is considered to be an unfair insurance practice. So be sure to always request for a written response within a few weeks.

Seek help from your doctor or insurance agents who know their way in and out of the system to better your chances and to know the options that are available to you.

Read all the fine print again and again and make sure that you have proper and sufficient knowledge of everything you have and are coming across. There are a lot of instances where in the given reason for the denial is questionable and even simply wrong. Do not assume that just because something they gave you is written down then it is also automatically correct. Know and review the state laws and find out optional steps available to you as well as your legal rights and that of your insurer’s and the common ground that you can meet.

File an appeal. To do this you must know the ins and outs of your health plans process. For most states, they require health plans to have two levels of appeal.  The first step of the appeal process is the internal appeal wherein you may request more detailed information and request the insurer to reassess its decision. The second one is the external appeals. This is filed in the event that the internal appeals have been worn out and the insurer refuses to reconsider your case.


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