Dealing With A Denied Claim

You just got an unexpected surprise in the mail. It’s a notice from your insurance company telling you they’re not covering your recent hospital visit.

Depending on your budget, being denied a claim can be frightening and frustrating. But not every denial is set in stone: consumers frequently take their disputes up with insurers over everything from disagreements about what services are supposed to be covered down to administrative errors.

If you think you’re being billed in error, there is a proper course of action for disputing a denied claim.

5 Steps For Dealing With A Denied Claim

1. Understand your policy. Do you get your coverage through your employer, or did you purchase a plan on your own? Knowing what type of insurance you hold will help you determine what rights you have under the law when appealing a denied claim. Before you proceed to the next step, make sure you’ve reviewed your “Certificate of Insurance” very carefully. This is the official legal document that will be used to determine the fairness of your rejected claim. Your health insurance agent or employer will be able to obtain a current copy for you. After going over the fine print, you may find that payment was denied due to an exclusion you may have overlooked, or you may not have followed your plan’s procedures for referrals.

2. Make an appeal over the phone. If you’ve reviewed your plan and still feel like your claim wasn’t handled properly, give your insurer’s service department a call. You may be able to settle the issue at this level.

Keep good records from the start: Make sure you keep record of your phone conversation, including the name of the person you speak with, and notes about your discussion. Add this to a collection of all the records you have, including any paperwork from you received from your doctor and insurer. If you can’t resolve the issue right there and then, confirm with the representative exactly when you can expect to be called back. Hold them to their word: If you don’t get your response on the date given, it’s time to hop back on the phone and firmly ask for answers.

3. Make a formal appeal. If dealing with your insurer on an informal level fails, it’s time to put it in writing. Ask your insurer for an appeal form, or if they don’t have one, find out exactly what processes they have in place to deal with your particular grievance.

Keep an eye on the time. Your appeal may have to be made within a certain timeframe for it to be considered for review. Make sure you know and meet all deadlines.

Now your dispute will go through your insurance company’s internal review process. If you disagree with the results of the review, the company may allow you to appeal their decision through a new panel of people who did not play a part in the original decision.

4. Get another opinion. If you’ve made it through your insurer’s multiple levels of appeal and aren’t satisfied with the results, it’s possible you can take the dispute to your state for an external review. Many states offer these programs, although they vary greatly from one place to another. Contact your state’s insurance department to learn about the external review process available to you.

5. Avoid common mistakes. Every year many appeals to state programs are not accepted for review. Common reasons include consumers not taking appeals through their insurer’s entire appeal process before turning to the state, not providing all the information required for a full state investigation, and not filing their appeal with the right agency.

You can easily side-step worrisome disputes with your insurer by knowing and following your plan’s procedures for care ahead of time. And remember; even if you don’t currently have a dispute over a denied claim, it’s important to be familiar with your plan’s appeal process in case you face one in the future.