A denied health insurance coverage claim can be more than upsetting. A March 2011 report by the Government Accountability Office shows that “nationwide data collected by HHS from insurers showed that the aggregate application denial rate for the first quarter of 2010 was 19 percent, but that denial rates varied significantly across insurers.” You do have a legal right to appeal, but appealing denied health insurance coverage can become a stressful or even intimidating process. Avoiding emotional arguments is key to the success.
Talk with Your Insurance Carrier
The first action is to talk with your insurance company to clear up any misunderstanding that lead to the claim denial. It is important to protest the denial quickly, as insurers have time limits on appeals. While you are collecting information to make an appeal it is important to keep organized—writing down names, numbers and dates. Ask for any person’s name immediately. If you are denied by the person you have first reached, ask for a supervisor and work your way up to find a manager who will help. Be perseverant!
Find All the Facts
The first step is to send a certified letter requesting the specifics so that you can be informed when you start the insurance claim appeal process. In the meantime, read your policy carefully to discover what benefits and procedures are included. Study the policy language to make sure that your treatment or need is included in your circumstances; for example, what is covered during a hospital stay is often not covered in a routine exam.
Your Doctor Can Help
If the problem is treatment circumstances, the doctor’s accounting person might be able to resubmit the bill: indeed billing staff do this routinely when they receive the insurance claim denial. As insurance firms often deny treatment claims that are specifically covered, you may need to ask your doctor to write a letter outlining the need and reiterating that the benefit is clearly covered in the policy.
Others Who Can Provide Support
Find other parties that can be tapped for assistance if your physician is not able to resolve the claim denial problem. For those using their employer’s health insurance, their insurance broker or human resources department may have someone who will help with your appeal. Your hospital or insurance firm may even have a patient advocate who is responsible for advising about claim denials (hospitals are required to provide this service as a part of the Patient Bill of Rights).
Non-profit Patient Advocates
Another avenue of aid is the various types of patient and health care advocates. These include non-profit organizations—such as Patient Advocate Foundation and the Center for Health Insurance Claims Advocacy, which provide patients with negotiation services to assist with illness related issues of all types.
Various levels of government also might be able to aid in your health insurance claim appeal. State insurance offices often have some type of support persons available. And the U.S. Department of Labor’s Employee Benefits Security Administration has a staff of experts who may be able to help. Such agencies as the Department of Health and Human Services, the Health Care Financing Administration, and their subsidiary agencies (i.e. Medicare), offer helpful online resources.
Always remember not to give up as your persistence may be a signal to the insurance staff to approve your denied health insurance coverage claim sooner. Many health plans deny claims routinely on the first request. Many persons you consult along the way will also be able to help you state your claim in clinical terms that will aid in your process. Remember that a calm and organized appeal will be treated in the same manner.
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