Denied Health Insurance Claim: Now What?

It is daunting to have your health insurance claim denied; your are in need of medical attention and that should be your main focus. Luckily, there are several things you can do to answer the question, “An insurance company denied my claim, now what?!” All insurance companies have an appeal process for any decision they have made.

The first step to successfully appealing your claim is to have a full understanding of “Why?”.
Insurance companies are mandated to give you full disclosure for why you have received a denied claim.

Explanation of Benefits Form: Denied Claim

Most often this information is provided to you with an Explanation of Benefits (EOB) form. It is in this form that insurance companies reference codes to explain their reasoning for accepting or denying a health insurance claim. The most common health insurance claim denial reasons are:

  • Your policy does not cover the specific services or procedures that you seek coverage for
  • Your procedure is deemed cosmetic, experimental, or medically unnecessary
  • You did not submit needed documentation required, such as a referral or pre-authorization (this sometimes is totally unbeknown to individuals when submitting a claim. If this is the reason for a denied health insurance claim, then it is an easier administrative fix)
  • You sought medical attention from an “out-of-network” provider (someone or an entity that is not acknowledged by your insurance company as being a credentialed source of health care. Example of such may be a Holistic Practitioner or Herbalist)
  • There has been a typographical error
  • There has been a missed deadline
  • Your policy may have limitations that you may or may not be aware of at the time of filing your health insurance claim

The Call for a Denied Health Insurance Claim

It would be wise to call your insurance company directly to also get a verbal disclosure of why your claim has been denied, and to explain this decision in terms that you, as an individual, can understand. If you are still stumped, ask “Can you please explain?” Furthermore, anyone you talk to through this process is part of your appeal, therefore we urge you to be as organized as possible and gather as much information (the name of whom you’re speaking to, a “call reference number”, or if your appeal is denied and filed, “a document image number”.)

Gather Information (Pre-Existing Condition, Reasons, Statistics)

Gathering as much information as possible on a denied claim is beneficial in gaining confidence on how to fight health insurance denial. Sometimes it comes down to a technical error on the claims form, such as the wrong date or insurance ID number.

Be thorough and proof read any documentation sent to and from your health insurance company. If you find an error on the part of your insurance provider, this should be brought to their attention as soon as possible in order to have the issue corrected and for your claim to be resubmitted.

Health Insurance Claim: Medical Services

In terms of documentation provided by you to support your health insurance claim, make sure that it underlines the medical services you seek and that they are absolutely necessary. No doctor would (or should) send out referrals, prescribe prescriptions, and/or perform procedures if it is not absolutely necessary; this is something that must be communicated properly to your health insurance provider. Therefore, all medical documentation you have to support your current medical state is pivotal in your claim and appeal process. This is even more important if you think your health insurance claim was denied due to a pre-existing condition. The help you need now is your primary focus.

My Health Insurance has been Denied… Now What?

When you are facing a denied claim, it is important to set up a strategy on how to fight health insurance denial. Once you have gathered all the facts as to “Why?”, you want to seek as much advice as possible on how to approach the matter. Contacting a long-term disability lawyer for a free consultation will be beneficial no matter what. Gaining legal insight and confidence in your appeal, at any level, is worth your time. Besides having doctor’s statements of why you’re in need of medical coverage, conducting your own research on studies that scientifically prove your treatment is necessary can help. It is pivotal that you know that ANY medical/ scientific evidence you or researchers can provide to support an appeal, to a health insurance claim denial, is valid!

What the Government Thinks

In accordance with Government Accountability Offices, it is totally worth your time to fight and appeal a health insurance claim that has been denied. According to the GAO, and its health insurance claim denial statistics, many denied claims are due to a simple coding error or a factual error, such as someone didn’t fill out the right box with the correct coding number, the diagnosis and treatment did not clearly state necessity, etc. What is deemed “medically necessary” may differ from one insurance company to another, but usually follows a set of guidelines and policies to determine whether a treatment has evidence of effectiveness for your specific condition, and therefore will be covered or reimbursed.

Contact Us for Legal Advice & Help with your Denied Claim

While the process can take time and energy, once the record is corrected and you re-submit your claim as an appeal, you have an excellent chance of winning. Some insurance deny claims in bad faith, in full refusal to confront the facts and documentation you provide. It is important to seek legal advice immediately if you feel that your insurance denial was a result of bad faith. You have your rights and these need to be protected to avoid long-term denial and for you to get better, feel supported and get on with your life!