How To Appeal A Health Insurance Claim Denial?

A health emergency can come along with a lot of challenges. Not only the patient has to pass through really tough times, but the family members also go through a lot of upheavals. In a scenario like this, a health insurance policy acts as a cushion. The health policy is supposed to support you financially, throughout the medical procedure. However, if you suddenly come to know that your insurance policy wouldn’t cover the expenses, how would you feel? Shocked? Devastated? For your information, your claim application can be rejected by the health insurance company. Don’t let panic strike because you have the option against the health insurance provider’s rejection of your claim. How? Find out below.

Why Does a Health Insurance Company Reject a Claim?

Insurance companies do have a strong reason for rejection and it is usually conveyed. If there is no intimation, a policyholder has the right to ask for the same. After you come to know the reason behind your claim rejection, you can make changes wherever necessary and reapply. After receiving a claim application, the first thing that a claim team does is to go through the applicant’s policy details.

The team checks and verifies the basic details, e.g. the names of the people who are entitled to receive coverage, how long is the policy valid, as well as inclusions. Some major issues that arise for a claim to occur include a certain issue that the health policy is not supposed to cover, the policy has expired, the application doesn’t have the required details, or the supporting documents are not attached. Following are some steps that you need to take in such cases.

Go Through Your Policy and Paperwork

Check your insurance documents. Go through the summary of benefits. Every issue that’s covered should be there in the paperwork. The document should also mention the exclusions or limitations, i.e. the issues that wouldn’t be covered under your health policy. The insurance company must have sent you a letter citing the reason for your policy rejection. Read through it carefully.

The letter should mention what your approach should be in case of rejection and how you can appeal against it. It should also tell you the source from where you can get help while initiating the procedure.

Who to Call for Help?

If you haven’t received any intimation from the insurance company and have no idea why your claim was rejected, call up the company and inquire about it. Don’t forget to ask them whether you skipped any of the vital information or there was a billing error. If you feel that you need to appeal against the decision of rejection to your claim, take help from the representative. Ask them if they could discuss the entire process with you or send you a detailed description.

While you are talking to the representative, make sure you jot down the name of the person you are talking to, the date of your conversation, and everything that was discussed. Keeping records is a must. In case the insurance company informs you that your doctor has left out some vital information or put in the wrong code, call the doctor’s office immediately and request the staff to rectify whatever mistakes have been made and forward the paperwork to the health insurance company. If you are receiving employer’s coverage, request your employer to send the insurance company a letter, explaining the reason why there is nothing wrong with your claim. That might help.

Learn About the Procedure to Appeal

If your company decides not to pay your claim, you have all the right to appeal against the decision. You are permitted under law to appeal with your insurance provider. You can also ask for a review conducted by an independent third party. That will be an external review of course. If you are appealing against your claim rejection, ask your doctor or the hospital to hold the bills until the insurance company contacts you back. Learn how you should file an appeal and what’s the deadline for it.

If you are not content with the results, you can opt for an external review. You will have four months to do that. If you are careful and follow the basic steps, you wouldn’t have your claim application rejected.