5 Things You Should Do When Your Healthcare Claim is ‘Rejected’

Healthcare claim rejected
September 30, 2015

Posted by MedbillingExperts / 0 Comment

Few things can be as frightening as learning that your health insurance company won’t pay for medical expenses. And when you come to know about this at the eleventh hour, you will live through a nightmare. If you are unlucky, you may get caught in the sinking hole into medical debt, and if it does happen, remember the law offers a way out.

Yes, until recently, the rules governing when, why and how you could appeal to an insurance company’s decision to deny payment on a claim, were all over the place. But today, thanks to ACA, the rules of the game have changed and become more streamlined for the betterment of all the citizens. What this means is that insurance companies can no longer conceal the reason behind the denial of your claim. Additionally, the law even makes it mandatory for them to guide you with regards to how you can appeal that decision. It also gives you the privilege to demand an internal review and direct them to reconsider the decision that you feel is dubious. And if you are not happy with the response to your appeal, you can also opt for an independent third-party to investigate your insurance company’s review.

Though these rules are applicable only for health insurance plans that were generated after March 23, 2010, or for policies that came into existence earlier and have since been altered in various ways, experts believe that it is a step in the right direction.

With this in mind let us take a look at steps that you can take if you ever find yourself at the receiving end of a denial letter:

Step 1: Check the details of rejection

A rejected claim will always be accompanied by a thorough explanation as to why this decision was made by the insurance company. Hence go through the nitty-gritties and try to understand the reason why the claim was rejected.

There are many instances where the claims are denied over simple clerical issues, such as a lost or misplaced documents, or even paperwork that was logged ‘in the system’ incorrectly. If you find yourself in such a situation, contact the insurance provider and try to clear things up. It might take a little extra effort to reach the appropriate person, but it will be worth it if your claim is approved.

Step 2: Ask the insurance company to reassess your claim

If your health insurance provider rejects to pay your medical bills, formally ask the company to take a look at your claim one more time. As per the law, you can file this plea for internal appeal within the first 180 days of being informed that your claim was rejected.

To initiate the internal appeal you have to first draft a letter to your insurer, requesting for a rational and unbiased review of their decision. Or, you can roll out the internal appeal by filling out the forms provided by the service provider.

Step 3: Look into external review options

It is no secret that health insurance providers do not always side with consumers during internal reviews. And in case you feel that you are cheated during the internal appeal, the law gives you the right to opt for an independent review, known as an external review.

External review can be overseen by the federal Department of Health and Human Services, independent review organizations, or the state itself, depending on your state and the type of insurance that you have.

Step 4: Make sure that you have collected every piece of vital evidence

If you wish to take your insurer to task for a wrong appraisal, you will have to be ready with plenty of strong evidence. Hence make it a point to gather every piece of evidence from medical records; accident reports; worksite investigation; medical expenses and other information to support your case.

Step 5: Get ready for your appeal

The claim denial documents received by you will have critical information about the appeals process. Make sure that you go through the details thoroughly, understand all the nitty-gritties and be extra careful about the deadlines. Remember that in any appeal, it is critical to adhere to the deadlines and make it a point that you don’t blow your chance because you missed certain technicalities.

You can also hire the services of a specialist such as an attorney to navigate through the intricacies involved in an appeal.

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