If you’re like most people, you’ll feel frustrated and helpless when your medical insurance denies your claim. After all, you have two options if you require medical attention but your insurance denies your claim: you can appeal the decision or you can pay for the care out of pocket.
The majority of claims are rejected for specific causes and reasons. The direct result of missing data is the reason your health plan is most likely to reject your claim. You can confirm this by making sure all pre-authorization requests were filled out with accurate patient information before filing an appeal for your denied claim.
For instance, does the doctor have the most recent version of your health plan’s identification card? Does the doctor have the most recent version of the diagnosis and procedure codes in order to properly fill out the forms? Is your social security number correctly listed?
You can proceed to the next step by confirming that you provided the physician with good documentation, and that they in turn provided the health plan with good documentation. Think suspicious when interacting with your health insurance provider.
Every call you make, every contact you have, and every bit of information you receive should be recorded. You can prepare for any appeals case by keeping track of all of your communications with the insurance company. It only takes one communication breakdown to create a problem.
Make sure you have read the appeals procedure in your company’s health insurance manual if you are dealing with an appeals claim for treatment coverage. The handbooks that their insurance provider will provide are typically ignored by patients. In these handbooks, plan requirements and appeal procedures are described in detail. If at all possible, you should confirm with your insurance provider that any treatment you intend to receive is covered by your plan prior to beginning it.
when it is required to appeal.
Since every plan should have a clear appeals process, you should follow it explicitly. To get the necessary evidence and expertise, you should speak with your doctor about appealing the claim. If you wait six weeks after a denial and you only have 60 days to appeal, you may already be out of time. Keep in mind that most insurance claims have time limits on when they can be appealed.
You should always make an internal appeal to your insurance company before turning to an external source, such as a federal or state appeals process. The majority of appeals follow the following process:.
Telephone Complaint.
Complaint in writing.
Appeal in writing.
Another instance where you should be very specific, citing your plan’s coverage guidelines and keeping track of all interactions with the insurance provider. Even though the insurance company will generally accept legitimate appeals, there have been cases of insurance fraud and health plans that don’t follow the rules that have been made public. A patient can use up all of their recourse against the insurance company and then pursue an appeal at a higher level by keeping track of response times and any necessary response times.
An appeal to a state or federal insurance oversight process is governed by laws in many states; these laws frequently permit an outside, expert review of the appeal. A board of qualified experts will then be able to evaluate your case on an individual basis after receiving accurate documentation and thorough medical support from your physical. Your insurance provider will not be able to reject the claim if an external appeal upholds it and reverses the denial.
Your best resources for obtaining approval for the treatment you require are familiarity with your health plan, your doctor’s knowledge of procedures, and a thorough understanding of the appeals process. Do not overlook the details, keep accurate documentation and review your coverage plans if you have any questions. Always keep in mind that you have options.
