What to Do if Your Insurance Claim is Denied
A serious illness or a lengthy stay in the hospital is always stressful. It’s not a time you want to be worried about your insurance coverage. Unfortunately for some customers, this is when they learn that their insurance company has denied their claim.
When a claim is denied, here are your options according to the New York State Department of Insurance suggests:
- You must read and understand your policy. The policy is a legal contract so you must understand your rights and responsibilities. If anything is unclear get clarification form your insurance agent or company. Also, failure to obtain prior authorization will most likely result in a denied claim by the insurer.
- What to do is a claim is denied during treatment. First contact your insurance company immediately. Keep notes of all conversation; including name of whom you’re speaking with, date, and time. You must listen carefully and make note of the answers you get. In addition check your policy or certificate of coverage to determine your appeal or grievance rights. Make note of any and all time frames and be careful not to exceed those times limits.
- Be persistent. Sometimes a simple error may have caused a denial. A billing error or incorrect code may have been entered, which can be resolved rather quickly. After your first conversation with the company and your claim is refused, be persistent. Insurers and HMOs are required by law to provide a written explanation of benefits and the reasons for the denial. Also a telephone number and address is provided so you can get in contact and get information on how to form an appeal. But don’t wait. There are deadlines of when an appeal has to be filed so do it as soon as possible upon learning you were denied.
- What to do if an insurer continues to deny a claim. Usually you begin by sending a letter to company asking them to reconsider your claim. Also you should provide specific reasons why you believe the claim should be paid. You should try and be as detailed as possible in explaining why your procedure or medication in needed. Then make arrangements for your medical records to be sent to the insurer to help support your position. Be sure to keep a copy of everything for your records. The insurer will then respond indicating the next steps in the process.
- Know your rights. If a health insurer denies or limits medical service because it is considered experimental, investigational or not medically necessary, then you have the right to appeal the decision. Request the insurer conduct and internal appeal to reconsider its decision. If you disagree with the result then contact the Insurance Department and request an external appeal conducted by medical professionals not affiliated with the insurer. You must request an external appeal within 45 days of the insurer’s decision on the internal appeal.
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