Denied a health claim? Now what?

By Insure.com

Everyone visits a doctor sooner or later, and these trips don't come at a small cost. That's why you have health insurance. But what happens when you know you need care and your insurance company says you don't? Most people are taken by surprise when a health insurance claim is denied.

Some denials are a consequence of actions within your control. For example, health plans often deny or return pre-authorization requests because of missing data. You can avoid this by ensuring your pre-authorization requests include accurate patient information. Ask your doctor to check diagnosis and procedure (ICD9) codes for accuracy.

Good documentation can also help you avoid denials. Though it may seem paranoid, write down the name of every person you talk to in reference to your health insurance problems and keep backups of all correspondence and paperwork. This documentation can be invaluable if an insurer denies your claim.

Additionally, it is important to know the health plan's requirements. Most patients do not read the handbooks their health plans provide, according to a study by the U.S. General Accounting Office, so they're unfamiliar with the plans' requirements. Consequently, many appeals stem from ignorance. Make sure ahead of time that the treatment you plan to receive is covered under your insurance.

What to do if your claim is denied

Enlist your doctor's help in making your case. Most plans grant or deny treatment based on whether medical intervention is necessary for your well-being and whether the treatment you seek is appropriate for your health condition. Ask your doctor to contact the plan's decision maker -- usually the plan's medical director.

When a claim is denied, your insurer should provide the following information:

• A statement of the specific medical and scientific reason for denial.

• A statement identifying the policy provision that excludes the treatment.

• The name, state of licensing, medical license number and title of the person making the denial decision.

• A description of alternative treatments, services or supplies that are covered, if there are any.

• Instructions for initiating internal appeals of denial, including whether your appeal has to be in writing, time limits, schedules for filing, and the name and phone number of a contact person.

• Instructions for filing an external request for review if the denial is upheld in the internal review.

If you do not receive that information from the insurer, ask for it in writing.

When an appeal is necessary

Every plan should have a clear appeals process that you must follow to the letter. You may have a limited period from the date you had the procedure to get an appeal under way, possibly only 60 days. Depending on your plan's procedure, you may have to start with a phone complaint, then move to a written appeal.

Continued: First step

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