How to Respond When Your Health Insurer Denies Your Claim?

When health insurance denies a claim, what should you do? Can you request an appeal? Let’s find out here.

The Next Steps to Take When Health Insurance Denies a Claim

Getting your claim denied can be a tremendous challenge. It can be time-consuming to file an appeal.

But when dealing with an insurance denial, there are things that you must do to continue fighting on your path to recovery.

Read: When Does Your Health Insurance Start? 

1) Remain Calm 

When you receive an insurance denial, you would be heartbroken. But you must not freak out.

Although it can be frustrating to see an insurance denial statement, you must remain calm. In that way, you can plan your next move.

Remember that it’s not unusual for health insurance to deny your claim. It doesn’t only happen to you. It happens to many owners of health insurance policies.

Read: What Health Insurance Covers Dexcom?

2) Check Your Policy 

After receiving the insurance denial letter, you should remain calm and check the details of your policy. Make sure to read the small print.

The letter must include details of the benefits that your insurer will pay and won’t pay. In other words, the letter will include why your claim has been rejected.

Check the reason for the rejection against the policy details. If you find a discrepancy, you must contact your health care provider’s billing office.

3) Call Your Insurer

Not all denials can be fixed easily. But it’s important to know who to ask for assistance. If you’re not sure why your claim has been denied, you need to call your health insurer.

Ask if the claim was denied because of missing information or a billing error.

Now, if you wish to appeal the decision, make sure to ask your health insurer’s representative about how to go over the appeal process.

When you do call your health insurance company, make sure to keep records of the call. Write the representative’s name, the date, and what suggestions are provided.

If your health insurer states that you forget some information or fail to use the right code, you must call your doctor’s office. Your doctor’s staff will fix the error and provide the paperwork to your health insurance.

Read: What Your Health Insurance Covers?

4) Know the Appeal Process

You must know that it’s your right to file an appeal. The law lets you have an appeal with your insurer and allow an external review from a third party.

But before you appeal, make sure that you know how to complete the process. Most health insurers will provide information about the appeal process on their websites. If it’s not available on its website, you may call your health insurer.

You must obtain detailed instructions on the proper way to file an appeal. Ask the customer support rep if there’s a deadline for filing an appeal.

You must let your doctor know that you’re filing an appeal. In that way, your doctor’s office will delay sending you bills. It will also prevent the office from moving your account to a collections agency.

5) Call an Internal Review 

The appeal process starts when you file a complaint to appeal a denied claim. The claim will be reviewed internally by your health insurer.

You may also request an expedited appeal if you’re in an urgent medical situation. The expedited appeal will require your insurer to decide in 72 hours after you have submitted your complaint.

Once the internal review has been completed, your health insurer will call you about its decision. If the internal reviewer overturned the initial decision, the treatment you received will be covered.

On the other hand, if the internal reviewer supports the initial decision, you can take it to the next level. That is, you can call an independent third party to do its own review.

You may also ask the help of your state’s Consumer Assistance Program to answer questions and to guide you in the appeal process.

6) Avoid Delay 

When submitting your claims, you should do it promptly. That is, it has to be done within the timeframe that your insurer has specified.

7) Avoid this Problem from Happening Again 

Before you get any medical service, make sure that you know what is covered by your plan.

If you’re not sure, make sure that you check your policy or just call your health insurer before you undergo the desired treatment.

Even if your doctor thinks that it’s medically necessary, you must still contact your insurer to make sure that the treatment is covered.

You should also follow every rule of your health plan. In many instances, your health insurance company may require that you request pre-authorization before getting treatment.

Another thing to consider is the limit on your benefits. To know these limits, you need to peruse your insurance documents. Again, you must call your health insurance company to find out more details about the benefits included in your policy.

You should also ensure that your healthcare provider is in your plan’s network. It’s especially true if you have an HMO policy. Keep in mind that your health insurer may not pay for your medical care if you received it from a provider that’s not part of your health plan. If this is your case, your health insurer will surely deny your claim.

Don’t Give Up

Filing an appeal can be arduous. It’s also challenging and it can eat a lot of your time. But you must remember that your health insurance company makes the appeal process complicated so you will give up.

But you should not give up. Make sure that you keep your focus. Always remember that a health insurance denial isn’t the final word. Consider it as a hitch in your plan.

The good thing is that there are tools that can help you fight the decision.

Conclusion 

When health denies a claim, you shouldn’t freak out. Follow the tips mentioned above to help you go through the appeal process. Here are some reasons why your health insurance won’t pay your medical bill.