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What to Do When Your Health Insurance Company Denies Your Claim

When you need medical care, the last thing you want is to worry about whether or not your health insurance will cover it. Unfortunately, there are many reasons why a provider may deny your claim. So what happens then?

The good news is that a claim denial isn’t set in stone. Your insurance company is legally obligated to explain why they didn’t pay your claim, and you have up to six months to appeal. Best of all, we’re here to arm you with everything you need to know in order to increase the chances that your insurer will reverse its decision. Keep reading for our guide what to do if your health insurance won’t pay for a medical service.

Find Out Why Your Health Insurance Claim Wasn’t Paid

Before you can fight a denied claim, you need to understand why it was denied. Here are the most common reasons why:

  • The claim has errors. As frustrating as it may be, a simple typo could be the cause of an unpaid medical bill. For example, a provider may code the submission wrong, leave information out, misspell your name or have your birth date wrong. These might all seem like trivial details, but if any of your information doesn’t match the health plan on file, it would cause a medical claim to be marked as denied.. If you find an error, ask your provider to correct the information and submit it again.
  • You used a provider who isn’t in your health plan’s network. Many plans will only cover providers and facilities in their network. If you go out of network, your provider may not cover the costs. Other plans may only pay for a portion of the out-of-network costs, leaving you financially responsible for the rest. 
  • The care you received isn’t covered. Similarly to the reason above, your health plan may only cover specific procedures. For example, cosmetic procedures such as plastic surgery are nearly always considered elective and so are not covered. Fertility treatments are only covered in certain states, and even then, there are loopholes that allow insurers to deny coverage.
  • Your provider should have gotten approval ahead of time. Procedures like an MRI or certain surgeries will typically require pre-authorization. If your claim was denied because it wasn’t pre-authorized, speak with the physician who ordered the procedure. They may be able to submit patient records to show you needed the service.
  • Your claim went to the wrong insurance company. If you’re married, you may have two health plans—one from your employer and one from your spouse’s employer. If this is the case, the provider may have billed the wrong company. This can also happen if the provider has outdated information because you changed insurers. Contact your provider to get to the bottom of it, or check your EOB to see if it is from the right health plan,

Once you know why the claim was denied, you’ll be able to quickly remedy the situation by contacting the right person—either your medical provider or insurance agent—for help before resubmitting the claim. Otherwise, you can move on to the steps that follow below.

Gather Your Evidence

When you contact your insurance provider about the denial, make sure that you have all the necessary evidence to show that the services you want covered are medically necessary. This can include referrals to specialists, prescriptions from your doctor, and any relevant information about your medical history that can act as proof that your claim needs to be covered. It will also be important to reference your medical plan’s medical policy bulletin or guideline for the treatment you received. You can find both of these online through your health plan’s website.

Submit the Correct Paperwork

The explanation of benefits included in your health plan will explain how to appeal a claim denial, but you can also call your insurance company directly to have them walk you through the process. It may be necessary to write a letter to your insurance provider. If so, be sure to include both your claim number and the number on your health insurance card.

Stay Organized

Remember, errors on a claim are one of the most common reasons why a claim gets denied. That’s why you’ll need to be as organized as possible with all your paperwork and information pertaining to a claim, down to the last detail. Keep everything in one place and be sure to take notes during every conversation with your insurance agent. Here are some things to record and keep track of:

  • The name and the job title of each person you speak with
  • The date and time of each conversation
  • A “call reference number” for phone calls with your insurer
  • A document image number (if an appeal was submitted)

Staying on top of all this information will help you build your case and ensure that your appeal process can move forward without delay.

Follow Up on Your Denied Claim

There’s some truth to the old saying “the squeaky wheel gets the grease”—at least, in the insurance world. If an agent from your insurance company says they’re going to resubmit your claim and it will take about a week to be processed, set a calendar reminder to call back in a week to check on the status. Remember, insurance providers are typically involved in many different cases at once. That’s why giving them a gentle reminder could help the chances of your claim moving along through the pipeline. 

Move Up the Ladder

So what happens if you’ve completed all the necessary steps with your insurance company but your claim has been denied a second time? Now it’s time to take it to the next level. The Affordable care Act requires that states set up an external review process for denied medical claims. To see whether your state has implemented the new guidelines yet, check the Centers for Medicare and Medicaid Services site.

Speed Up the Process by Filing an External Review

If you’re in urgent need of medical care, you may not have the time to wait the full thirty days for an answer from your insurance provider. In this case, you can file an expedited appeal. You’d simply need to show that the timeline for the standard appeal process would seriously jeopardize your life or your ability to regain maximum function,” according to Healthcare.gov.

If this applies to you, you’ll need to file an internal and external appeal at the same time. If your injury or sickness makes this too difficult to do on your own, your doctor will be able to file an external appeal on your behalf. A final decision for an external appeal must be made as quickly as your medical condition requires, and at least within four business days after your appeal is received. A final decision can be communicated over the phone, but it must be delivered as a written notice within 48 hours. 

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