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How to Appeal a Denied Health Insurance Claim

By on March 18, 2014 in Health Insurance, Insurance

How to Appeal a Denied Health Insurance ClaimHealth insurance in America is a virtual requirement to avoid financial catastrophe if you become seriously ill. One uninsured stay in a hospital can top hundreds of thousands of dollars.

But maybe you did the right thing and got an independent health insurance policy. Or your employer provides adequate coverage to you and your family. You paid your premiums each month on time, and everything has been going smoothly.

All of a sudden you get a denial to claim for a medical procedure, test, or doctor’s visit. You get a letter in the mail but it is full of terms you don’t understand. Is the decision final? What can you do?

It’s time to start gathering data because you can appeal a denied health insurance claim.

How to Fight a Denied Health Insurance Claim

Here’s a walkthrough of why health insurance companies deny claims and what you can do about it.

Why Denied Claims Happen

First you must understand a few reasons that can cause a health insurance company to deny a claim. The basis for all denials is the insurance company’s coverage policy. The policy dictates exactly what is and isn’t covered. All problems stem from this policy; if you or your doctor try to file a claim on something that isn’t covered then the company will obviously deny the claim.

Some of the issues that can cause a claim to be denied are:

  • Is the treatment, procedure, or medicine medically necessary? If not then the claim will be denied as excessive.
  • Is the treatment, procedure, or medicine a proven method of treating a medical issue? Is it accepted as scientifically appropriate or does the scientific community deny its validity?
  • Was the treatment or procedure incorrectly coded by the healthcare provider? One keystroke wrong on the claim by the doctor’s office can lead to the claim being denied.

You’ll need to contact the insurance company to learn exactly why your claim was denied. That information will help you gather the information necessary to fight the denial.

What Information You Need to Fight a Denied Claim

The easiest denial to appeal is incorrect coding. You’ll need to know what the insurance company received, what the provider input, and what should have been input. Again a simply keying error can lead to a denied claim.

Above that you will likely need assistance from the provider to help you validate the necessity or scientific validity of the treatment you were given.

Get Help to Fight the Denied Claim

You shouldn’t try to fight a denied health insurance claim alone. The healthcare industry and especially health insurance industry is a confusing mess of terms and policies written in 7 point font with 1,000 words on each page. You aren’t an expert in the field, so get some help.

You should look for assistance from:

Your healthcare provider.

The provider wants the claim to go through as well. They know that a major claim coming back to the individual means they in turn have to get the individual to pay up. They don’t want to have to send you an invoice and convince you to pay. If you can’t pay they might have to send it to collections. They would much rather file the claim with the insurance company to get the highest payout possible, so use them to fight your denial.

A healthcare advocate.

Many states have for-profit and non-profit organizations that will be a healthcare advocate for you. Some employers offer this service for their employees. A healthcare advocate is someone who is an expert in the healthcare and health insurance field. They can fight on your behalf since they know the industry inside and out. There may be a charge for this; it just depends on the service you are using.

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