How to Fight Health Insurance Coverage Rejections
Health insurance companies are in business to make money. Unfortunately, sometimes that means medical claims are denied and a patient is left to cover medical bills related to a claim. Health insurance companies have strict standards about the types of medical situations and expenses they will cover, and the slightest detail can cause a claim to be denied. Fortunately, there are ways to fight medical claims effectively that often result in claims being covered.
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Things You'll Need
- Records from the doctor, hospital or clinic that you visited
- Billing statements from the medical provider
- Explanation of benefits from the insurance company
Instructions
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1
Determine the reason your claim was rejected. There is typically a reason code provided on your explanation of benefits, although they're not always clear. Call the insurance company for details about why the claim was rejected.
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2
Decide whether the rejection was legitimate. If the insurance company denied payment for a prescription that is clearly not covered on your formulary, that is a legitimate rejection. If you feel that your claim should have been covered, proceed with trying to fight the denial. The most common reasons claims are inaccurately rejected are that the insurance company determined the treatment was not medically necessary, or there was a billing error between the provider and the insurance company.
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3
File an appeal with your insurance company. Request an appeal form from the insurance company, or ask for instructions on submitting an appeal. Write a letter to accompany your appeal, explaining why you feel the claim should have been covered.
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Contact the medical provider to explain that the claim has been denied but you have filed an appeal. Ask for an extension to avoid being sent to collections for not paying the bill. Confirm that the provider has your correct insurance information and the correct billing address of the insurance company.
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Obtain records from your physician or other provider that will help document the medical necessity of the treatment you received. Often, insurance companies deny claims based on very little information. When provided with the appropriate documentation, they often reverse their rejection. For example, if you were instructed by another medical provider to go to the emergency room, providing proof that you were directed there can help reverse a denial for emergency room payment.
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Have the medical provider resubmit the bill to the insurance company. Even if you were not able to determine a billing error through phone conversations with representatives, sometimes resubmitting the bill can cause it to go through without a problem.
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File a complaint with your state's Insurance Commission and the Attorney General's health care department. Obtain forms for filing a complaint by contacting each organization through its website. The Office of Attorney General Health Care helps mediate medical claim disputes, and the Insurance Commission investigates insurance companies for wrongdoing.
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Tips & Warnings
If you're certain your claim is being denied inappropriately, yet your efforts have failed, enlist the help of an attorney, particularly if your medical expenses are extremely high. Often, insurance companies don't want to deal with the hassle of working with an attorney, so you may be able to get your claim paid easily.
