What To Do if Health Insurance Claim is Denied in Edmond

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If your health insurance claim is denied, there are different things you can do in order to get insurance to pay for your medical coverage. When a claim is denied, it leaves patients with the responsibility of footing large medical bills or going without necessary treatment.

Read the Policy Carefully

You need to figure out if your claim was legitimately denied. The health insurance company may have interpreted the clause in the policy differently than how you understand it. If the ruling doesn’t seem like it is fair then there could be a chance that it isn’t. You should contact the company in order to make sure you have a thorough explanation of the denial so you know how to move forward.

Ask Your Insurance Agent or HR Department

Your insurance agent or the HR department at work can help you make sure the coverage is in your best interest. You should contact them for support with any healthcare details. Depending on the situation, they should be able to help you understand the appeal process, help explain your benefits, and even contact the insurer on your behalf.

Know Why the Claim Was Denied

The first thing you will need to do is make sure that you understand why the claim was denied. It could be an error or you could need to file an appeal, but the basis of your appeal is going to depend on why the insurance company denied the claim.

Contact the Insurance Company Directly

If you aren’t getting any help from your agent or HR department, you can also contact the insurance company directly. You will need to be persistent. You should have a record of all phone calls, including the positions and names of everyone you speak with, along with references to ticket numbers associated with each call. Follow up each call with a letter stating what you understand of the conversation. Start with each person who denied the claim and write to the supervisors. Include copies of bills, relevant forms, supporting documents, the policy number, and concise and clear descriptions of the problem. You should request that there be a response within three weeks. Keep records of every piece of correspondence and send letters by registered mail so you have copies of the receipts. You can explain the negative effects of the denial but avoid any blaming or rude statements. In your correspondence, ask specific and detailed questions. The questions shouldn’t be ambiguous to a third party in case someone else looks into your case. The more proactive you are, and with due diligence, the more likely you will have a positive response from your insurance company.

You Have the Right to Appeal the Denial

Under the Affordable Care Act, you have the right to appeal any denials. The right is to an internal appeal that is conducted by your insurance company. However, they can still deny the claim, and then you also have the right to an external independent appeal. This applies to both post- and pre-service denials. This means that if you want to get pre-authorization for care that your insurer rejects, you have the right to appeal.

Make Sure the Claim Was Properly Coded

In a majority of cases, it’s not the policyholder that is filing claims with the insurance company. Instead, the hospital or doctor files the claims. If you are staying within the provider network then the filing process is handled by a medical professional. Errors can still happen. Billing codes could be incorrect or there could be some inconsistencies in the claim. If you do get an explanation of benefits showing the claim was denied and you are required to pay the bill yourself, make sure that you know why you are having to pay before you do. Call both the medical office and the insurance company. Be sure that there aren’t any errors in the claim and that you fully understand the reason for denial. The claim denial could still be wrong and you have the right to appeal. However, now you know that it’s not something such as a wrong billing code that caused the denial.

If you are seeing a provider that is not in your insurance company’s network then you will have to file the claim yourself. The hospital or doctor will make you pay your bill up front and then you will need to get reimbursement from the company. The amount you expect to get reimbursed for will depend on your coverage and whether or not you have met your deductible yet. In order to not get denied, you need to understand the requirements for filing an out-of-network claim. These usually have to be submitted within a specific time frame. If you do end up with a denial, it could be due to how the claim was filed.

It will help you to know the price of the treatment you were denied. The better informed you are, the better the system will work for you. You should understand why your insurance company wants to deny certain services and treatment. The answer is usually with the price. Until recently, it was hard to come up with prices of treatment but there are different resources you can use to get prices. Being aware of the price of the procedure and the price that your insurance company is willing to cover can allow you to negotiate how much you end up paying.

Understand Out-of-Pocket Costs

Sometimes people think their claim was denied when they have to pay out-of-pocket costs. However, it’s important that you read and understand the explanation of benefits you get from your insurer since this clarifies why you may be asked to pay for the claim. For example, if you have a $5,000 deductible and get an MRI billed at $1,300, you are going to get a bill for this because you haven’t met your deductible yet. This doesn’t mean the claim was denied. This service was still covered but the covered service counts toward the deductible until you have paid this amount in full. It’s only after you have already met your deductible that your insurance company starts paying. Once you reach your deductible other costs are covered.

Contact an Attorney

If you have tried everything in order to do your appeal, you can contact a health insurance claim denial attorney. Working with an Edmond insurance attorney can help you with the appeal process and represent your best interest. The appeal process can be confusing and, in order to prevent another denial, you may need some extra help.

Doug Terry

In 1999, Doug became one of the founding partners at an Oklahoma City law firm. Doug’s practice evolved away from representing insurance companies, and he began representing individuals and businesses who had been treated unfairly by their insurance companies. This type of practice became his passion. Doug found that standing up for normal people, like those he had grown up around in Oklahoma, who had been taken advantage of by huge insurance companies was what he was meant to do.

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