How To Fight a Health Insurance Claim Denial ?

You might run up against a health insurance claim denial when you use a medical service. Fortunately, routes are available for disputing claim denials, including getting help from the government in many states.

If Your Claim is Denied

Start by reviewing your paperwork file. Then call your health plan's customer service line. Often, mistaken denials can be cleared up at this level. Be sure to take notes on all phone conversations, including the date and time of the call, the names of the people you talk to and what was discussed.

Formal Appeals

If speaking with a customer service representative does not work, you may have to escalate to a formal written appeal.

Your insurance policy will outline the paperwork your health plan requires you to file. You can expect to provide a great deal of information in writing, including copies of bills, your healthcare provider's name, address and phone number, and your physician's statement about why your treatment was or will be necessary.

Many health plans have several steps in the appeal process. If your initial appeal is denied, you most likely will have additional appeals available. The entire appeal process should be outlined in the benefits booklet you received from your health plan.

Independent Reviews

In many states, you can ask your state insurance commissioner's office to perform an independent review of your dispute. This step is usually taken after you go through your health plan's internal appeals process first.

To find out about an independent review, check your health plan benefits booklet (sometimes referred to as “Evidence of Coverage”), which in some states is required to inform health plan members about appeals options external to the health plan. Another important resource is your state’s insurance department, or agency.

Arbitration

Some health plans offer arbitration, in which an independent third party reviews the dispute and recommends an outcome. Whether the arbitrator's ruling is binding depends on the state and the health plan.


If arbitration is offered under an employer-provided health plan, federal law says you can't be charged for using it.


source:
http://healthinsurance.about.com/od/claims/a/fighting_claim_denials.html