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12 tips to follow when appealing a health insurance claim denial

Q: I've been having trouble getting my health insurance company to pay a claim. What should I do? Who can help me?

A: Navigating the inner workings of the health care system can be extremely time-consuming, frustrating and sometimes even fruitless. Minor mistakes and discrepancies in reporting information to a payer can prevent a claim from being accepted. Here are some of the key mistakes that could be causing your claim denial:

• Erroneous identifying information (name misspelled, date of birth mismatch, subscriber or insured group number missing or invalid).

• Terminated coverage.

• Required pre-authorization.

• Non-covered services.

• Missing or invalid coding.

Beyond these relatively simple reasons, other, more complex reasons that you may be unable to pinpoint could be causing the denial. So don’t just assume the denial is correct. If you think your claim should be covered, take action. Most health insurance companies want to do things right.

Here are 12 steps you can take to appeal your insurance company’s denial:

1. Prepare yourself with all the information. In addition to the "explanation of benefits" from your insurance company, obtain an itemized bill from the provider. Sometimes a quick review of the itemized bill can uncover mistakes that otherwise would have made your claim payable.

2. Use resources at hand. Your insurance agent or group policy administrator (human resources department) can provide guidance.

3. Make sure you filed properly. A filing error on your part should not result in a denial. But you may be off on technicalities or just simply filed the claim too late.

4. Exercise your right to an external review. If your insurance company’s internal review provides a denial, then you may have the right to an external review.

5. File a formal grievance. This action will require you to appear before a committee to state your case or to choose someone to represent you at a committee hearing.

6. Do some shopping. See what other doctors in the area are charging for the same procedure or treatment. Present this information to your insurance company.

7. Follow up with deadlines. If your insurance agent or policy administrator doesn’t close the case within 30 days, call the health insurance company yourself. Write another letter with your original correspondence attached. Send it to the company’s customer service department and president. As the head of a company, I appreciate being copied on correspondence from our customers.

8. Get your doctor on board. If your doctor says the treatment was necessary, you might find your road to claim approval easier.

9. Prove previous creditable coverage. Was your claim denied because of pre-existing conditions? Until a certain provision of the federal health care reform law takes effect, insurers still can deny claims for individuals who had pre-existing conditions but didn't have previous coverage.

To arm yourself against this sort of denial, be sure to keep a copy of the certificate of creditable coverage that each health insurance company sends when it terminates a policy. You should give a copy of this form to the HR professional at your new employer; if you're insured on your own, be sure to send a copy of the certificate to your new insurance company. Proof that you had previous creditable coverage is extremely important when it comes to claims being paid.

10. Determine whether the claim was denied because of recent coverage reductions. If you were not properly notified about coverage reductions, that’s a violation of the law.

11. Enlist a medical bill negotiation company. You may find experienced medical cost containment companies that previously just served businesses now are serving consumers. These companies typically employ a team of medical professionals, nurse bill auditors, certified coders and negotiators who review medical bills every day.

12. Talk with your provider. If your claim was denied because the provider was out of network or it wasn't a service allowed under your policy, your provider may be willing to negotiate with you on costs. Some providers will offer a discount if you pay cash, or they'll help set up a payment plan.

Remember that it’s crucial to stay organized throughout this process. Keep a log of all your communication -- emails, letters, phone calls. Stay positive throughout the process, and know that every time empowered consumers work to resolve medical billing errors and inaccuracies, you’re helping create a better, more efficient health care system.

is CEO of Chicago-based Rising Medical Solutions, a medical cost containment/care management company serving the workers' compensation, group health, auto and liability markets. Beans founded Rising in 1999. Since then, Beans has received a number of honors, including Business Council Advisory Man of the Year and Midwest finalist for Ernst & Young Entrepreneur of the Year. Rising has appeared several times on the Private Company Index's Top 10 Growth list and Inc. magazine’s Inc. 5000 list.

Beans earned a master's degree from MIT’s Entrepreneurial Masters Program and a bachelor's degree in finance from Boston College.

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