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It is stressful if your health claim gets rejected. You visit the hospital, get tests done, take medicines and then when you submit the bill, you get a denial letter. Often people get confused and do not know what to do. This creates further tension thinking about where the money will come from. But it is important that you do not panic. Claim denial does not mean that you will never be able to get coverage. Often claims are rejected for simple reasons which may be correct. First of all, you must understand what was the reason for the denial and what options you have.
Important to check EOB
You should first check your Explanation of Benefits or EOB. It states why the claim was rejected. Unless you understand the reason, you will not get a solution. Read the EOB letter carefully.
Coding Errors Piss You Off
Sometimes a claim is denied due to coding errors or incomplete documents. If the documents are not complete, the system rejects them. It is very important that every form and bill is correct.
Network and Coverage Issues
Sometimes the service is not in the coverage of the plan or a network doctor is not used. Your plan only covers in-network doctors. If an out-of-network doctor is consulted, the claim may be rejected.
Contact Insurance
If you don't understand anything, call your insurance company and ask. Every plan has its own helpline number where you can get help. It is very important to keep the documentation ready so that you can get your matter clarified.
Whoever is insured has the right to appeal
Every insured person has the legal right to appeal his or her denied claim. Appeal means that you submit your claim for a re-review where a new team or medical expert looks at the case. This right is protected at the federal and state level. Appeal is an option in both private plans and employer-based insurance. You have to appeal in writing and attach certain documents. It is very important to follow the timeline. In some plans, the appeal has to be made within 30 days and in some, up to 60 days are given. You will get this detail in your plan documents.
How to write an appeal letter
The appeal letter should be simple and focused. You have to mention your name, plan ID, date of service and claim number. Then you have to write the reason for denial which is given in the EOB. After that you have to explain why you feel the claim should be approved. If the doctor has support or any note then do attach that. Also submit medical reports, prescriptions, test results along with the appeal letter. The insurance company has to be convinced that your claim was valid and the service was medically necessary.
Appeal Letter
Write policy number and member ID clearly
Attach a copy of the denial letter
Doctor's supporting note is a must
Include all bills and receipts
Internal Vs External Review
Often people wait only for internal review but if the internal appeal is also rejected you have the right to external review as well. External review means that a third-party medical expert, who is not from the insurance company, looks at your case. This process is impartial and there is a chance of a fair decision. External review is done under federal law and many times the decision is given in favour of the insured people. For external review you have to fill out a form and send all the details and supporting papers in it.
Coordination with doctors is a must
When a claim is denied the role of your doctor becomes important. Sometimes a claim is denied because the insurance company feels the service was not medically necessary. If your doctor writes a detailed letter saying the service was necessary for the patient your case becomes stronger. You should get a statement from the doctor in which he has written for which condition the treatment was given and if it had not been given the patient's health would have been at risk. This document carries a lot of weight in the appeal process.
Pay attention to the timing
Whenever you get the claim denial letter, check the calendar at that time. Every plan has a deadline for appeal. Many people delay and then their appeal gets rejected simply because of being late. You should start the appeal process within a few days of receiving the claim denial. If you are busy, explain the process to a trusted family member or legal advisor so that they can help you. It is very important to appeal on time otherwise your case will not be accepted.
Extra Support Options
If you are confused or the process seems difficult, you have options for extra help. Every state has a Health Insurance Consumer Assistance Program where trained staff gives you free guidance. This staff understands your case in detail and guides you at every step. They explain the documents to you and also give you the format of appeal. All the steps like how to write it, what to include, to which address it has to be sent, are explained to you. Sometimes the language of the forms is difficult or you find it difficult to understand, this assistance program explains everything in a simplified manner.
There are also many nonprofit health legal aid offices that help low-income families with health insurance matters. Using them is beneficial when you are filing your first claim or your first appeal. These offices work with you to fill out documents and help handle the follow-up process. These workplaces also offer assistance from interpreters if you are not comfortable with English. By and large, this back framework gives you certainty that you are not alone and that you can viably seek after your case.
Freelancers and Small Business People
Health claims are even more important for people who are self-employed or run their own small business because they do not have employer-based support. Such people have to understand their plan details very clearly. If you are a specialist, you ought to guarantee that you do not utilize out-of-network specialists unless there is a crisis. Little trade proprietors ought to teach their staff around what steps to take if a claim is denied. Being proactive saves from financial stress in the future.
Appeal is also possible in government programs
If you are using Medicare or Medicaid, you still have the right to appeal. Many people think that in government programs there is no option after a denial but that is not the case. In Medicare there are 5 levels of appeal process which is done step by step. The first level is redetermination where the Medicare contractor looks at the case again and reviews whether the denial was justified or not. At this stage you have to send your documents and explanation. If you do not get relief from there, you can appeal at the next level where there is an independent review which is done by a neutral party.
If the decision still is not in your favor you can go for an administrative hearing. In Medicaid also you can appeal to your state's Medicaid office but the process is slightly different in each state. In many states you have to request a fair hearing where a judge hears your case. Documentation is very important in these cases also. Keeping a copy of every document and mentioning the correct date makes the process smooth. You also have to keep in mind timelines as there is a specific deadline for the appeal. If you file late your appeal could be rejected. To appeal in government programmes, you can also take help from any legal aid office which guides you in filling the forms and gathering evidence.
Final Thoughts
Claim denial can be frustrating but don't be afraid of it. Every insured has the right to appeal his or her denied claim. First, read the EOB letter, understand the reason, and prepare documents. Write the appeal letter and keep in mind the timeline. A doctor's supporting documents make a strong case. After an internal review, pursue an external review if needed. People who are self-employed or have low incomes can use state assistance programs.
Medicare and Medicaid users can also seek relief through their rights. If your health claim is denied, handle it with resolution. The right approach can get your valid claim approved. Taking health coverage is not just about paying a premium, it is also important to understand it and follow its rules. The more understanding you have of your plan, the better will be your outcome when there is a medical emergency or expense.