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Better Coverage Article
Challenging A Denial Of Healthin Insurance Coverage
Receiving a letter from your healh insurance company advising you that they have denied a benefit claim can be upsetting and create a great deal of anxiety. Don’t be intimidated into thinking that you have to pay the bill yourself, though, because you have certain rights under both federal and state laws to challenge a denial of coverage.
The first thing you should do when you receive a denial of coverage letter is review the benefit booklet from your insurance company to determine what services are and are not covered. Many times it will not be clear as to whether the service you received should be covered, so you should check the “explanation of benefits” language in the denial letter that you received. This should explain why payment was denied. If it is not clear, then you should call your insurance company immediately and request that they send you a written copy of the specific wording in your policy that supports their denial of your claim.
Sometimes a denial of coverage is simply due to a billing error. To determine whether this is the case, contact the billing office where your service was performed and request an itemized accounting of their charge, verify the information when you receive it and contact your insurance company if you discover any errors.
Once you have determined that denial of coverage in your case is not due to a simple billing error, then your next step is to contact your insurance company and ask to speak with a case manager who can explain the appeal process to you. Ask the case manager to send you a written explanation of the appeal process as well.
The timeframe for filing an appeal is usually within 180 days of the denial, but be sure to confirm the exact deadline for your insurer. If a denial of coverage is related to a pre-approved service such as surgery or some other treatment and this service is medically urgent, you can file an urgent care claim, which is usually reviewed within 72 hours.
If your insurance coverage is through your employer, make sure to ask your health benefits administrator for assistance with this process. It is also important to get your doctor involved as well. Ask him or her to write a letter describing your condition, the treatment that he/she recommended for you, why it is medically necessary and what your prognosis will be without it.
Many insurers will provide an appeal claim form to be completed. If this is the case with your company make sure you answer all the questions completely and accurately. If an appeal form is not provided, then you will need to write an appeal letter on your own. Your letter should include basic information such as your contact information, your insurance plan number or group number, your member ID number and the claim number assigned to your case. Include the name and contact information for your doctor as well as the letter that he or she has written for you. Explain in detail why you believe the denial should be reversed an include copies of all related bills. Keep a copy of the appeal letter or form for your files and send it via certified mail with a return receipt requested.
If your initial appeal is denied, do not give up. Other options for assistance are available. Start with contacting the Patient Advocate Foundation. They can provide guidance on how to proceed. You can also contact your state health commissioner and even your U.S. Representative or Senators for assistance if necessary.
Helpful Resources
In addition to helping you find the best insurance rates possible, we also offer a useful resource section with informative articles on health and life insurance topics that can help make the process of buying insurance a bit easier. Understanding the difference between the various types of both life and health insurance policies is key to making certain you get the best policy for your particular needs.
