What To Do If Health Insurance Company Denies Your Claim

A Health Insurance Claim can be denied for many reasons. Under Affordable Care Act the claimant can appeal for a denied claim to the Insurance Company. The client is given a time of six months before he can appeal for a denied claim. The various ways in which the client can appeal for a denied claim are as follows:

  • The client can have a clear understanding of the benefits of his claim by filling up a standard form Explanation of Benefits (EOB). The EOB uses codes and defines why the insurer was denied the claim.
  • The client can appeal for a denied claim in two basic ways --- an internal appeal or an external review. In case of an internal appeal the Insurance company is asked to conduct a full and fair review of its decision. In doing so the Insurance Company must speed up its process. In the case of an External Review, the case is generally appealed to an independent third party which decides whether the Insurance company finally pays the claim or not.
  • The insurer can also call the Insurance company and ask for an explanation, the client has the right to this information from the Insurance Company under the law.
  • Sometimes errors can happen on the part of the client while filling up the form for example spelling mistakes, wrong policy number. These mistakes should be corrected before proceeding further with the claim. Errors can also happen on the part of the hospital authorities or the concerned doctor.
  • The client must make sure that he has all the evidences to show that all the services he wants covered are medically necessary.
  • Sometimes referrals, prescriptions and any other relevant information which has not been provided earlier might serve a very useful purpose for reclaiming a denied claim.
  • If the claim appeal does not work with the Insurance Company the client can take one step further and file an appeal through the Department of Health and Human Services.
  • To speed things up one can also file an expedited appeal to the Insurance Company. If the client cannot do so on his part due to his ill health then the doctor concerned can file an appeal on his behalf.
  • The claimant can also consult medical billing advocates to find out if any duplicate charges or charges for any cancelled tests have been levied by the Insurance carrier. These professionals then negotiate with the medical care authorities and the Insurance company to lessen the costs.
  • The client must make sure to refile his claim within the defined time frame. The letter of appeal should include the contact information of the person insured, subscriber number, the concerned doctor, the hospital in which the treatment was done and the case reference number given by the Insurance carrier.
  • If the coverage of the Insurance Company is through an employer or an individual policy one can also opt for the state’s appeal process. The State’s Insurance regulator then handles the process and tells the client how to handle the claim.