How to Resolve a Claim Dispute With Your Health Insurance Provider

Just because your health insurance provider has denied a claim doesn't necessarily mean that it won't pay some or all of it. Here are the steps to responding effectively to claim denials that you feel are not justified.

Difficulty: Moderately Easy

Instructions

Things You'll Need:

• Health Insurance
• Pads Of Paper
• Pencils Or Pens

1. Find the brochure or statement document that outlines your medical insurance coverage.

2. Go to the exclusions section and read it carefully.

3. Highlight any exclusions that may even remotely relate to your denied claim.

4. Gather together all claim denial notices, medical billing statements, and other documentation such as notes. Circle reference or invoice numbers and dates.

5. With this information, call the customer service division of your health insurance provider.

6. State your purpose clearly to the representative, indicating that after careful review of your coverage, you believe your claim should be paid.

7. Document all calls, writing down the date and time of your call, the full names and extensions of all company representatives you speak with, and the results of such conversations.

8. Insist that the representative give you a date by which your claim will be resolved, and call that representative back if resolution has not occurred by that date.

9. When the claim is paid, double-check your summary of coverage to make sure the amount paid agrees with the terms of your plan; for example, that the company pays 60 percent as stated in your coverage agreement, not 30 percent.

Tips & Warnings

• Read the explanation of the claim denial carefully, and if the office staff of your medical professional have failed to provide all information to the insurance company, call the office staff first.
• If you demonstrate a knowledge of your coverage, you are more likely to get the attention of the company service representative.
• Try calling early in the day if you are being left on hold for extended periods at later call times.
• Remember to speak slowly, calmly and politely to company service representatives; they did not make the rules or the decision to deny your claim.
• Be persistent and firm in your resolve to either get the claim paid or receive an understandable explanation, perhaps in writing, as to why the claim cannot be paid.
• If you feel your claim is of an exceptional nature or requires more consideration than a frontline customer service representative can provide, ask to be directed to a supervising claims adjuster for additional consideration.
• Documenting all calls is critical to resolving drawn-out disputes.
• Talk to your physician about the denial of any claim that uses the words "experimental," "nontraditional" or "unconventional" as justification, and ask him or her to help resolve your claim.
• Coverage of new procedures, medications and treatments is constantly being updated, so don't be put off by initial responses that deny your claim.
• Keep your cool: avoid losing your temper, shouting or lecturing about "the way things ought to be" when conversing with a company service representative.
• Don't simply accept that something that used to be covered is no longer covered without a complete, and perhaps written, explanation.
• Some health insurance providers count on your giving up after a period of time, so be persistent.

on 8/1/2006 Though insurance carriers and medical providers are often on opposite sides of the fence when it comes to claims, it's best to assume that both are being honest in their dealings with you. Errors occur, as do misinterpretations, but communication can solve those issues. Assuming one or the other is trying to somehow cheat you is not only wrong, it may prevent your claim from being correctly adjudicated.