When you or a loved one is in the hospital, the last thing you want to think of is how you’re going to pay your medical bills. Having your health insurance claim rejected is almost the ultimate insult to injury. The good news is that no matter the reason, your insurance provider is required to inform you of their denial, and you have the right to appeal it within six months of the notice they provide.
Ascertain the Cause of Denial
The first thing you need to do is look at the EOB (explanation of benefits) from your insurance company explaining the reason for the denial of coverage.
The exact reason for the denial may be found in the form of codes that may require you to reference a key, usually provided on the same document. If, after going through the forms you’re still unable to figure out what the exact issue was, speak to an agent. They are obligated to tell you why your application was denied.
Check Your Paperwork
Sometimes, applications are denied because of simple mistakes or errors like names, incorrect date of service, wrong insurance ID number, date of birth, etc. If the error involves inaccurate information, it may not be readily apparent that such a mistake has been made.
Start with your policy document and walk yourself back through the claims process, ensuring all information is complete, accurate, and submitted properly.
Gather Your Evidence
Get every single thing you’ll need to make your case. You will need the documentation pertaining to your policy and claim, as well as any bills, prescriptions, tests, diagnoses, and medical histories. Anything that indicates your situation should be covered, whether in voice or writing, should also be collected. Any and all of these could play a critical role in your appeal.
Use Standard Appeals Forms
It is not just enough to compile all these and mail them to the insurance company. Your insurance provider has an internal appeal process, and in most situations, your appeal will be processed more efficiently if you follow it. There will also be a stipulated process for requesting an external review if they still deny your claim.
In more urgent situations where life or functional capacities are at immediate risk, you can request an external review even if you have not been able to complete the internal process.
Follow-Up and Document Everything
Make sure to follow up on all your claims and submissions. Take notes, and document any dates, times, and names. Always find out when to expect a response or some other development. Take note of who you spoke to and follow-up promptly. When speaking to a new agent or adjuster, reference this information so you can make sure they are aware of everything that’s happened with regards to your claim or appeal.
Arbitration
If an external review still fails to approve your claim, there may be a voluntary or mandatory arbitration clause. It is strongly recommended that you consult with a lawyer if you are ever asked to waive your rights to sue, and this is not uncommon in situations that move towards third-party arbitration. At this point, or any point in the process where you feel you may not understand your rights as an insured patient, an attorney who is well-versed in insurance law can help protect your rights and ensure you get the compensation you deserve.
