How to appeal when your medical insurance declines your claim

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If you are like most people, when your medical insurance declines your claim, you are left feeling helpless and frustrated. After all, if you need health care and your insurance is saying you don’t, you have two choices – appealing your claim or paying for the treatment out of pocket.

Most claims are declined for specific reasons and causes. The most likely cause for your health plan to deny your claim is a direct consequence of missing data. Before appealing your denied claim, you can verify that by assuring any and all pre-authorization requests were filled out with accurate patient information.

For example, is your social security number correctly listed? Does the doctor have the most current copy of your health plan’s identification card? Does your doctor have the most up to date copy of diagnosis and procedure codes in order to fill out the forms correctly?

By verifying that you have submitted the good documentation to the physician and they in turn submitted good documentation the health plan, you are ready to move to the next level. When it comes to dealing with your health insurance company, think paranoid.

Document every phone call, every contact person and every piece of information you are given. It only takes one break down in communication to cause a problem; by documenting all of your communication with the insurance company, you are pre-preparing for any appeals case.

If you are facing an appeals claim for treatment coverage, be sure you’ve reviewed the appeals process in your company’s health insurance handbook. Most patients overlook reading through the handbooks their insurance company will provide. Plan requirements and appeal processes are detailed in these handbooks and you should make sure that your plan covers any treatment you are going to receive before the treatment is received, if possible.

When An Appeal Is Necessary

Since every plan should have a clear appeals process, you should follow it explicitly. You should talk to your doctor about appealing the claim so they can provide supporting documentation and expertise as needed. Remember, most insurance claims must be appealed within a limited amount of time, so if you wait six weeks after a denial and you only have 60 days to appeal; you may already be out of time.

You should always appeal internally to your insurance provider before going to an external source such as a government or state appeals process. Most appeals have a process that goes as follows:

· Phone Complaint
· Written Complaint
· Written Appeal

This is another area where you should be very specific citing the coverage rules of your plan as well as documenting each contact you have with the insurance company. While the insurance carrier will approve the majority of valid appeals; there has been documented cases of insurance fraud and health plans that do not play by the rules. By documenting response times and any required response times; a patient can exhaust their option against the insurance carrier for a valid appeal and then take it to the next level.

Laws in many states govern an appeal to a state or federal insurance oversight process; these requirements often allow for an external, expert review of the appeal. By providing accurate documentation and detailed medical support from your physical, a board of qualified experts can then judge your case on an individual basis. If an external appeal validates the claim and overturns the denial, then your insurance company will not be able to deny the claim.
Knowledge of your health plan, your doctor’s knowledge of procedures and a detailed review of the appeals process are your best tools to getting the approval of the treatment you need. Do not overlook the details, keep accurate documentation and review your coverage plans if you have any questions. Remember, there are always options.