Health insurance companies often deny pre-authorization requests for testing or medical treatment. Sometimes, the company refuses to pay the medical bill after you have already received the services. You feel punched in the gut when you receive a bill, sometimes for hundreds of dollars, with a note from the care provider that your insurance denied your claim.
Many times, the denial seems unfair. You may feel trapped and assume there is nothing you can do, but if this has happened to you, you do have some options. You can appeal the denial, but the first step is to understand why the claim was denied.
Reasons the Insurance Company May Give for Denying Your Claim
- The claim was not covered under your health insurance plan. Read your policy carefully. You may be interpreting a clause differently than the insurer is interpreting it. Contact your insurance company and ask for a detailed explanation of its denial. You need to understand this in order to pursue an appeal.
- The service was not “Medically Necessary.” You will need to get your health care provider to explain, in writing, to the insurance company why the service was medically necessary if already performed, or is medically necessary so that your insurer will commit to covering the procedure.
- The service is, or was at the time it was performed, experimental or investigative.
- You failed to get preauthorization for the service. Most insurance plans now require healthcare providers to get preauthorization before they provide certain medical or surgical services. Discuss this with your physician.
- Another insurance policy is responsible for the claim. If you have two insurance plans, for example, you and your spouse are both covered through your work, one plan may be expected to pay first. This is also true if the healthcare services provided to you were the result of a car accident, the insurer for the at-fault driver may be expected to pay your bill.
- You received care from an out-of-network provider. If this was due to an emergency, you need to provide this information to your insurance company.
- There is an error somewhere in the process. For example, a billing error may have occurred, such as the wrong code used by the medical biller.
If your claim was denied for any of these reasons, or because you were told simply the service was not covered, you have the right to an internal appeal.
How to File an Appeal
Call your insurance company. Have them explain to you in detail why your claim was denied. Also, ask them to explain to you how to file an appeal. Follow the appeal instructions precisely.
Write an appeal letter. This is the most important part of your appeal. The purpose is to convince the company that it should pay your claim. Your letter should include:
- A brief description of your medical condition including why the service was, or needs to be, performed.
- Reference the portion of the insurance policy that you believe says the service is covered. Use specific language from the policy indicating the service should be paid for.
- Attach a statement from your healthcare provider who performed or ordered the service that explains why the procedure is medically necessary, or if it was already performed, why there was no time for preauthorization.
- Wait a few days, then call and verify the company received your appeal documents.
- Follow up as much as necessary.
Be sure you keep a file documenting everything you have done. Any time you have a conversation with an insurance representative, document the date and time of the call, who you spoke with, and a summary of your conversation. If you are told to call back because the person you need to talk to is away, note the date and time of your call and the reason you were given to call back.
If your internal appeal is denied, you can then contact your state’s insurance commissioner and request an external appeal. The National Association of Insurance Commissioners maintains a list of all state commissioners and information about how to contact them.
Contact us for Help
Depending on the amount of money involved, you may decide to do this appeal yourself. If a large amount of money is involved, or you just feel you need help with the process, contact us at Burman Law. Our slogan is “Mike Will Fight to Make it Right.”