Read your Evidence of Coverage or Summary Plan Description thoroughly. In other words, get to know your policy, and learn what your limitations and exclusions are. Look at whether the medical procedure you need or desire is fully or partially covered before you go through the hassle of trying to get a potentially rejected claim overturned.
You pay monthly health insurance premiums for a reason, and you want to be certain you'll receive the benefits your policy covers when the need arises. But when your insurance company rejects a claim for an expensive medical procedure that you're certain was covered and medically necessary, do everything you can to change the insurer's mind and get the bill paid. Learn here how to fight a rejected insurance claim and breathe a sigh of relief.
Things You'll Need
- Insurance policy
- Medical bills
- Medical records
- Cancelled checks
Figure out why your insurance company rejected your claim. Compare the rejection notice or Explanation of Benefits form your insurance company sent you with your medical bills and check for charges or expenses that may have been coded incorrectly. Usually, the rejection notice will only give a basic reason and won't describe the rejection in detail. Call your insurance company and get a deeper explanation.
Notify your doctor or hospital immediately if you find charges on your bills for procedures or services you never got. Get the bill adjusted and call your insurance company immediately about any errors you find.
Follow your insurance company's rules as much as possible, no matter how cumbersome they can be. For example, pre-approval may be needed before certain medical procedures will be covered. You may be asking for a claim rejection before you even send the claim in if you don't get permission for the medical service you're seeking.
Talk to a customer service representative and inquire about the appeal process if the insurer won't budge in overturning its rejection. Ask where you can get the appropriate forms, and what your time limits are for filing an appeal. Ask about the full appeal procedure and don't let anything slip by. Insurance companies will scrutinize everything, and so should you.
Follow up with your insurance company with a letter from your doctor if the insurer says your claim had no medical necessity or was experimental. A letter from your doctor will hold a lot of weight, and will serve as hard evidence explaining why you needed the procedure for the diagnosis he rendered. Your doctor should be very cooperative in providing the information you need to get your rejected claim paid.
Gather medical records, bills and canceled checks relating to your claim and file copies of them with your appeal in writing the same day you request a review over the phone. Send your appeal paperwork by certified mail, return receipt requested. Adhere to deadlines and follow your insurance company's rules exactly. If you lose your appeal, check with your state insurance department to determine if it will conduct an independent review of your claim.
Tips & Warnings
- Insurance companies are often guilty of simple administrative errors and claim rejections can be resolved with a simple phone call.
- Take good notes and keep a journal of all your medical procedures. Note the names of claims representatives you talk to and on what dates you talked to them.
- Large insurance companies, like Aetna and Humana, post their Summary Plan Descriptions on their websites for easy online access.
- Check your medical records and bills to see if your diagnosis was coded incorrectly. This can be easily rectified by having your doctor resubmit the bill with the correct diagnosis.
- Don't depend on your doctor to know everything your insurance policy covers.
- Don't delay an appeal process because many insurance companies hold true to their deadlines and won't budge, even if you're a day late.
- Every state has its own external review process, and some only review certain types of cases.
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