Medical bills are stressful, especially when you find out that your insurance claim has been denied. However, there are several steps you can take to find out what prevented your medical insurance from covering your procedure. Read on to find out what you can do when your health insurance claim is denied.
Why would my claim get denied?
There are a few reasons your health insurance would deny your claim. Consider some of the following:
- Procedure deemed not medically necessary
- The procedure not eligible under your health plan
- Claim not filed in enough time
- The procedure has not proven effective
- Went to an out-of-network provider
- The procedure wasn’t preauthorized
- A deductible was not yet met
What to Do When Your Claim is Denied
Insurance claim denial is overwhelming, and many do not know where to begin the process of investigating it. Here are a few steps you can take to help you know what to do when your claim is denied.
Check Explanation of Benefits
First, take a look at your explanation of benefits (EOB). Your health insurance sends one when you file a claim. It will outline what your insurance company paid and what was not covered. The EOB will also explain why your claim was denied.
Next, review your summary of benefits and coverage (SBC). This will explain what benefits you have through your insurance and covered services. Your SBC also tells you what deductibles, copays, or coinsurance you are responsible for paying.
If you are unsure what your EOB or SBC means, give your insurance a call. This way, they can talk you through your benefits and coverage.
Review the No Surprises Act
Beginning on January 1, 2022, the No Surprise Act took effect. This is a federal law that protects people from unexpected medical bills. It prevents you from receiving unexpected bills from
out-of-network services at an in-network facility. Review this act to see if it covers your denied claim.
Call Your Health Insurance Company and Healthcare Provider
It is common for claims to get denied because of billing errors and/or missing information. Before you make the call, make sure you have your insurance card, the details of your claim (provider, date, reason), and your explanation of benefits. This will help the call go more smoothly as you investigate why your claim was denied.
If there was an error in why your claim was denied, your healthcare provider will need to be contacted. Ask your insurance to call your healthcare provider to settle the dispute. In some cases, you may have to also call your provider to resolve the issue.
Talk With Your HR Department at Work
Many people receive their health insurance through their job. If this is the case with you, your HR department may be able to help you understand why your claim was denied. The HR department has an active interest in making sure your claims are covered since your employer is paying your insurance premium.
File an Internal Appeal
The Affordable Care Act allows people to file an appeal when a claim has been denied. To do this, you will need to complete a few steps.
First, find out from your insurance company when the deadline is for filing an internal claim.
Next, you will want to ask your insurance if there is a specific form you will need to fill out. You will then need to resubmit the claim along with the EOB that was sent with the claim denial.
Furthermore, you will want to get a letter from your provider that explains why you received the procedure/treatment. It is also helpful to include any medical records, test results, or any additional information that will help support your claim.
You can also receive help through your state’s Consumer Assistance Program. If it is available through your state, they can help you file your internal appeal.
If you use Medicare or Medicaid, the claims process is different. Contact either Medicare or Medicaid to find out the process for filing your appeal.
File an External Appeal
If your internal appeal is denied, there is one final way to try to appeal the decision. This is through a third party, also called an external appeal. This removes the final decision from your insurance company to the third party. Whatever decision is made, your insurance must honor it.
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