Receiving a claim denial from your health insurance company can be frustrating and confusing. It can feel like a roadblock in accessing necessary medical care. At Medwise Insurance Advocacy, we understand the stress and uncertainty that come with claim denials. This blog post will provide a step-by-step guide on what to do when your insurance denies a claim, empowering you to navigate the appeals process and fight for the coverage you deserve.
Understanding Why Claims Are Denied:
Before taking action, it’s crucial to understand why your claim was denied. Common reasons for claim denials include:
- Lack of Prior Authorization: Some procedures or treatments require pre-approval from your insurance company. If you fail to obtain prior authorization, your claim may be denied.
- Incorrect Coding: Medical billing codes are used to identify diagnoses and procedures. Incorrect coding can lead to claim denials.
- Non-Covered Services: Your insurance plan may not cover the specific service you received.
- Out-of-Network Provider: If you received care from an out-of-network provider, your claim may be denied or paid at a lower rate.
- Missing Information: Incomplete or inaccurate information on your claim form can lead to denials.
- Duplicate Claims: Submitting the same claim multiple times can trigger a denial.
- Timely Filing Issues: Insurance companies have deadlines for submitting claims. If you miss the deadline, your claim may be denied.
- Experimental or Investigational Treatment: Insurance companies often deny claims for treatments they deem experimental or investigational.
Steps to Take When Your Claim is Denied:
Review the Explanation of Benefits (EOB): Your EOB will explain why your claim was denied. Carefully review the denial reason and any instructions for appealing the decision.
Contact Your Insurance Company: Call your insurance company to discuss the denial. Ask for clarification on the denial reason and what steps you need to take to appeal. Take detailed notes of your conversation, including the name of the representative you spoke with and the date and time of the call.
Gather Supporting Documentation: Collect any documentation that supports your claim, such as medical records, doctor’s letters, and prior authorization forms. If the denial was due to a coding error, ask your provider’s office to correct the code and resubmit the claim.
File an Appeal: Most insurance plans have a formal appeals process. Follow the instructions provided by your insurance company for filing an appeal. This usually involves submitting a written appeal letter and supporting documentation within a specific timeframe.
Write a Compelling Appeal Letter: Your appeal letter should clearly explain why you believe the claim should be paid. Be concise, organized, and professional. Include the following information in your appeal letter:
- Your name, policy number, and claim number
- The date of service and the provider’s name
- The reason for the denial
- A clear and concise explanation of why you disagree with the denial
- Supporting documentation, such as medical records and doctor’s letters
- A request for a specific action (e.g., payment of the claim)
Meet Deadlines: Pay close attention to deadlines for filing appeals. Missing a deadline can result in your appeal being denied.
Follow Up: After submitting your appeal, follow up with your insurance company to check on the status. Keep records of all communication with your insurance company.
Consider a Peer-to-Peer Review: If your appeal is denied, you may have the option to request a peer-to-peer review. This involves having your case reviewed by a medical professional who is not affiliated with your insurance company.
External Review: If your insurance company upholds the denial after the internal appeals process, you may be able to request an external review from an independent third-party organization. Your state insurance department can provide information on the external review process.
Seek Help from a Medical Billing Advocate: Navigating the appeals process can be complex and time-consuming. A medical billing advocate can help you understand your rights, gather supporting documentation, and negotiate with your insurance company on your behalf.
Common Questions About Claim Denials:
Q: My claim was denied because my doctor’s office didn’t get prior authorization. What can I do?
A: Contact your doctor’s office and ask them to obtain retroactive prior authorization from your insurance company. If they are successful, resubmit the claim.
Q: My insurance company says the service I received is “not medically necessary.” What does that mean?
A: “Not medically necessary” means your insurance company does not believe the service was essential for your diagnosis or treatment. You can appeal this denial by providing medical records and a letter from your doctor explaining why the service was medically necessary.
Q: How long does the appeals process usually take?
A: The length of the appeals process can vary depending on your insurance company and the complexity of your case. It can take several weeks or even months.
Dealing with claim denials can be a daunting task, but it’s important to remember that you have the right to appeal. At Medwise Insurance Advocacy, we can help you navigate the appeals process, understand your rights, and fight for the coverage you deserve. Don’t let a claim denial discourage you from seeking the care you need. Contact Adria at MedWise today for a consultation, and let us be your advocate in the complex world of health insurance.