Here are the steps you should take if your health insurance company denies your claim.
Until a few years ago, the rules regarding why, when, and how you could appeal an insurance company's decision to deny payment on a claim were all over the map.
They differed wildly from state to state and even employer to employer.
Today, thanks to the passage and implementation of the Affordable Care Act (ACA), these rules are now uniform (for the most part, at least—more about that in a second) across the country.
What this means for you is: 1) insurance companies are now required to tell you why they denied your claim, and 2) they also have to tell you how you can appeal that decision.
It also means you can ask them to reconsider (by conducting an internal review of) a decision you find questionable. And if you don't agree with their response to your "appeal"? You can have an independent third-party investigate your insurance company's review.
There is a bit of a catch to all of this, unfortunately. These rules only apply to health insurance policies created after March 23, 2010. The rules also apply to plans created earlier but have since been changed in various ways.
Some insurers are better than others and you are free to shop around for an insurance company that will treat you fairly. QuoteWizard can help connect you with top insurers so that you can compare health insurance plans with the coverage you need.
If you think appealing these kinds of decisions is a waste of time, by the way, think again. If a 2011 US Government Accountability Office report is anything to go by, appeals were successful more often than not, even before the ACA stepped in and made the changes mentioned above.
Specifically, the report in question found that 39 to 59 percent of appeals made directly to insurance companies resulted in a reversed decision. External appeals were nearly as successful, with 54 percent of the ones conducted (as part of the same GAO report) in Maryland ended with the insurer overturning their denial.
Another reason you should appeal any claim denials you disagree with: administrative errors are responsible for many of them.
Now that you're fired up about making an appeal to your insurance company, you're probably wondering how you go about filing it.
Before starting an "internal appeal" request, make sure it hasn't been more than six months since your claim was denied. Appeals have to be filed within 180 days.
If you're still within that window, your next step should be to do a bit of homework. That means:
Another couple of calls you may want to make before you move ahead with your initial appeal:
Your doctor—This is especially important if your claim was denied due to some sort of clerical error. It's possible your physician could help by explaining why you needed the care your insurance company is refusing to cover.
You should also request copies of any lab results, medical records, x-rays, or the like. These could help support your claim if you wind up asking your insurance company to conduct an internal review.
Someone in your employer's HR department—They also may be able to call or send a letter to your provider and support your need for the denied service or treatment.
Relevant researchers or scientists—Was your claim rejected because the insurer declared that the care you received or need to receive isn't scientifically proven or isn't medically necessary? If so, it may be worth your time and effort to track down some of the physicians, specialists, or scientists who have worked on studies that support your denied treatment. They might be willing to review your medical records or even submit a letter to your insurance company on your behalf.
If you ask for an internal review, give your doctor's office and even your hospital a heads up. That way they can hold off on sending any bills until your case has been settled.
With all of that prep work out of the way, you should be ready to move ahead with your appeal.
In most cases, that will mean filling out a bunch of paperwork that's provided by your insurance company. You'll also likely be able to include with that paperwork any additional information you want the company to consider, such as the physician or employer-related letters mentioned earlier.
Once you've sent in your appeal, your insurance company has to complete its review within certain periods of time depending on the situation. For example, the review has to be done within 30 days if your appeal is for care that you haven't yet received, and it has to be done within 60 days if you've already received the care in question.
Once the interview review has been completed, your insurance company must provide a written response that explains its decision. They also have to inform you how you can go about filing for an external appeal.
If the company that provides your health plan continues to deny your claim after going through the steps detailed in the section above, you may be able to ask for an external review to be completed.
(Actually, if your situation is urgent—such as if your life or your ability to "regain maximum function" are at stake—you can file internal and external appeal requests at the same time. You don't have to wait for an internal appeal to be completed before you ask for an external one to be done.)
Not all claim denials are eligible to be appealed in such a fashion, though. Instead, the only cases that are likely to be approved for external review are ones that involve:
Other than that, the external appeal process is much simpler than the one related to an internal appeal. All you have to do is file a written review request within 60 days of the final decision regarding denial.
After that, a third-party conducts the external revied and either agrees with or reverses your insurer's decision.
If your denial is overturned, your insurance company is required by law to accept that decision. It's also required to provide you the payments or allow you move ahead with the services requested in your claim.
If you need help with your external appeal, check to see if your state has a Consumer Assistance Program. This information can be found at The Center for Consumer Information & Insurance Oversight. They may be able to help you with various aspects of the process.
Also, if you want, you can appoint a representative, like your doctor or some other medical professional who is knowledgeable about your condition or situation, to file an external review on your behalf. For more information on how to do this, or to download and print the forms related to it, go to http://www.externalappeal.com.
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