There are very few things in life more frustrating than having a medical claim denied by your health insurance company. This is true especially when it involves some type of surgery or medication that is urgently necessary.
There is a possibility that your claim is denied for any number of reasons. Provisions set forth in the Affordable Care Act include additional rights and capacities for appealing the company’s decision. Among them is an extension of the time you have for an appeal, which is now increased to six months. Your insurer is mandated to inform you as to why your claim was rejected.
However, even if denied, you do have ways to engage with the insurance company in an effort to get them to reconsider. You do need to prepare your case thoroughly before you present it. That means you gather all the information needed to present the strongest argument about why the company can’t deny your claim.
Here are the ways to do just that, in case you find yourself in this unfortunate position with your provider.
Get the Reason First
In order to build a solid case, you need to know the reason they denied your claim. You should receive an Explanation of Benefits (EOB) form that features codes. These codes explain how your insurer came to their decision. The EOB describes what the codes mean so you can better understand the explanation. Yet, in some cases, the codes are not as clear. You may not fully comprehend how they came to use the codes provided.
Be certain that you are thoroughly apprised of the situation. If the jargon is too technical on the form, you have every right to contact the company directly and ask they give further information that explains their decision. Do not relent until you understand their denial, even if you do not agree with it. We will address that part, but first things first. You must get clarification on the issue.
Search for Errors
In some instances, a denial is merely the result of a clerical error. Therefore, before you build a whole case to present to your insurance company, troubleshoot this area. Perhaps it is something as simple as your name being improperly spelled. Maybe they have somebody else’s ID number in your file.
Be sure to comb through all the paperwork related to your claim, the I’s are dotted and T’s crossed. Should you find a mistake, bring it to their attention. That might be all that is necessary to resubmit the claim and get it approved.
Build a Case
This is the part where you gather all of the documentation and proof to demonstrate that the services and treatments you wish to have covered are necessary. This includes prescriptions, referrals, any paperwork or testimonials from medical professionals that point to your medical history. You can strengthen your case if you have some sort of precedent in the form of a reference in your health plan’s medical policies or guidelines that support your case.
Submitting the Proper Documents
The appeals process might require you submit written correspondence to the insurance company. Do this by sending a formal letter or by filling out their standard appeals form. Either way, do not delay the process simply because you filed the wrong paperwork or initiated the appeals process incorrectly.
Keep a File
Do not expect the insurance company to have all of your information organized. Before you send in anything, make copies for your records. Keep all paperwork related to your claim in one file for easy reference.
That also includes any notes and other information pertaining to the case. Always ask for the name and position of anyone you speak with on the phone. It is helpful to get information like call reference numbers and other identifying numbers for the claim. Good organization will be one of your greatest allies in this process.
Follow Up
Your initial contact with the insurance company will get the ball rolling. Make sure it keeps moving in a timely manner. Get in touch with them periodically to follow-up on how things are progressing.
A customer service rep can inform you that there are steps they need to take on their end. Trust that they will perform those steps, but verify they happen. Follow-up a week or ten days after you speak to somebody. The squeaky wheel gets the grease. Therefore it is easy to get lost in the size of an insurance company’s bureaucratic maze.
Remain Calm and Polite
Claim denials are frustrating. Often, the longer you go without the medical care you need, the angrier you can become. When you do speak to someone on the phone, chances are the customer service representative on the other end of the line is not the person who denied your claim.
Keep that in mind as you move through the process. Sometimes these reps become a helpful partner to get you through this ordeal. It often pays to be nice to them even if you have called about the very same issue four times in a row.
A Higher Authority
If you are not having any luck with your insurer and you get denied again, you can take the matter to an external review board under the rights and provisions of the Affordable Care Act. Should you still be seeking satisfaction, you can consult your state legislators to find how to present your case to an impartial entity.
Time is of the Essence
If they deny your claim, you may not have the luxury of going through the lengthy process of an appeal with your insurance company. In cases like these, you can request an expedited appeal when you file in the event your life is in danger without the necessary treatments that you are seeking.
You can also file an appeal with the external review board at the same time. It cuts out any additional steps you might need to take in the event you get denied a second time. It also helps speed the process so you can act accordingly in getting your health issues resolved.
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