Resolving Health Insurance Disputes
Date Added: July 11, 2008 12:16:59 AM
Sometimes a claim may be denied for one reason or another. Here are some of the common reasons:
- A claim may be deemed duplicate or inauthentic where the health insurance provider accidentally submits the same claim more than once for payment. Because of the high levels of health insurance fraud, insurance plans tend to shun such claims.
- It may be that your policy doesn’t cover the service or product in the claim. For example, some plans don’t cover elective procedures or dental services.
- Most plans do not cover services or products that the medical community consider to be experimental and have not been proven to be safe and effective.
If you believe your insurance benefits claim was inappropriately denied, there are several options that you can pursue.
In order to begin, you will need to find out about the appeal process available under your health insurer’s internal review process by calling the number on the explanation of benefits (EOB) document that you received when you signed up for your health insurance plan. The internal review process tends to vary from one company to another.
Before you appeal, here are a few things you must do:
- Review the benefits linked to your health insurance plan
- Request a full explanation, if possible in writing, of the reason for the denial
- Ask your doctor or health care provider to write a letter explaining why you need the treatment or service
- Include as much supporting documentation as you can gather
- Seek assistance from your doctor, health plan or state department of insurance
- Where your health insurance is provided through your employer, it is imperative you speak to your company benefits manager or human resources staff before taking any further action.
How To Appeal A Claim
· Many health insurers have multiple levels of review, which allow you to appeal your claim more than once internally. However, this depends on the company.
· Many health plans leave the reviewing of claims to independent outside medical experts.
· Medicare beneficiaries are required to follow the appeal process outlined in their Medicare handbook.
· Medicaid beneficiaries should call their state Medicaid office to get information about the appeal process they must follow.
If you have exhausted the internal review processes provided under your health insurance plan and you still believe that your claim has been inappropriately denied, you can give someone else, such as your doctor, written permission to appeal on your behalf.
Otherwise you may appeal directly to external or independent review programs available in 43 states as well as the District of Columbia. The external review process is overseen by the state you reside in and provides an additional, legally mandated appeal.
What types of insurance coverage are subject to external review?
1. Individually Purchased Coverage
2. Health Insurance Through an Employer
What types of disagreements qualify for external review?
1. Medical Necessity
2. Experimental / Investigational
3. Dollar Value of Claims
3. Dollar Value of Claims
What information will I need for an external review?
- Your health insurance ID card.
- A copy of the letter from your health plan informing you they have denied your internal appeal.
- The explanation of benefits / booklet and other materials you received from your health plan describing your coverage.
- A short explanation of the service or procedure for which you made the claim. Your doctor will usually help you with this.
- Copies of the medical records outlining the service or treatment in question.
Read more about health insurance in Cobra Your Health Insurance Plan After Your Employment Ends.
