It can be overwhelming to find yourself requiring medical services and working through the insurance process. Just as you are starting to feel better, the last thing you need is to receive a denial of payment from your health plan.
You certainly should not ignore any claim denials received from your health plan, but you shouldn’t stress over it either. Studies have shown that many claim denials are simple coding errors or other errors on the bill or claim form. In few instances it is possible the health plan has denied payment because it has determined that your medical service was not “medical necessary.”
Here are some tips to follow if you or someone you know receives a denial of payment from your health plan:
- Call the customer service number listed on your explanation of benefits document. (CAUTION: You may experience a long hold time so be sure you give yourself ample time and a comfortable chair) It is highly likely the person you are speaking with is reading from a script, so remember he/she is doing their job and you may need to escalate to a manager.
- Ask for clarity on why the claim is specifically denied. Are they looking for more information? If so, from whom? Is there an incorrect code? Are they denying because of an internal policy? If so, where is that policy documented so you can research? Don’t hang up until you are comfortable and understand what next steps to take with the responses received.
- Document your call and determine your next step based on what you learned. Do you need to speak with the hospital or physician’s office to understand why something was coded a certain way? Do you need to submit additional information to the insurance carrier to have the claim processed?
- Get the claim reprocessed. If your claim was denied for needing additional information, you can often provide the information needed over the phone or by fax. When you provide that information, demand that your health plan reprocess your claim on an expedited basis. They don’t need an additional 30 working days to pay your claim.
- File a written appeal to your health plan. If your claim was denied for a reason such as the services were not medically necessary or the services were not a covered benefit under your health plan, you should file a written appeal to your insurer. When preparing to write your appeal, be sure to state within the first two sentences why the health plan should pay your claim. The additional paragraphs should then support your statement. Be sure to gather any information that supports your reason why your health plan should approve your claim and include that with your appeal.