Your Health Insurance Claim Was Denied…What Now?

At some point in our lives, we must deal with health insurance. There is no escaping it. Finding out how to deal with the unexpected is essential. It may seem simple. We give them our card, they bill the insurance, and we pay our portion. But what happens when the health insurance company does not want to pay? Do you know your next steps? This can be a scary situation to be in. There is a lot of unknown here. What should you do first?

Clarification

Before giving in and paying the total amount, find out why they denied it. A good practice is to keep all paperwork. Review everything you received or sent in to see if it was a simple error. Did you need to fill something out or write something that needed to be corrected? A simple clerical error would be the easiest. After that, you would fix and resubmit. Another piece of information is double-checking that the service is covered under your policy. Depending on the carrier, they may not list it as medically necessary. There are many rules to follow, and if you do not, it can be a reason for them to deny. An example would be getting pre–authorization. If you are not quickly seeing the reason for denial, you will need to make that dreaded call to find out why. Without knowing the cause, you cannot find a solution. 

Records 

Keep every piece of paper that has anything to do with your medical bills and insurance. Get organized at home. Have a secure folder or box that is always kept in the same place. Unless you want to print all the correspondents, have the same setup in your email. Anything related moves to the folder. Whenever you get anything related, place it in. Then when issues arise, you are not searching your home, or emails for the documents. It will be simple to find anything that you need. 

Two P’s

There are two P’s that you need to remember during this process. Those are Prompt and Persistent. If you wait for months to take care of a claim, it will make it more difficult. Depending on the company and state you live in, there can be different deadlines you have to work within. The other one is being persistent. It is common to have to resubmit claims or appeals more than once to get it taken care of. It can feel like the insurance companies are hoping you will give up. Don’t let them win. Keep contacting them. In this case, the more you reach out, the better chance you have of your issue being resolved. 

Appeal 

If resubmitting a claim does not solve the issue, the next step would be an appeal. This can be a little tricky as not all insurance companies have the same rules. The first step will be to do a little research. Find your carrier’s appeal process. This should be available to you on their website. It should also be given to you when you sign up or renew your contract with them. Just like filling out your medical forms, you do not want your appeal to be denied because of a clerical error. A great idea would be to get a second pair of eyes on the situation to ensure you are not overlooking anything. The appeal process can take time, and as mentioned above, you need to be persistent. Check in to see where they are in the process frequently. 

Get Help

Talk to coworkers. See if any have dealt with similar situations and what steps they took. Your employer may have contacts that could be useful as well. If you have done all you can and still hit a wall, another option exists. After doing all you can, contact your state insurance commissioner’s office. Before reaching out, make sure you have all your records. From the beginning to the end. Have records of all the steps you have taken and everything your carrier has sent you. Going to them too early will result in them sending you back to take more steps on your own. They should be contacted as the last result when you have exhausted all other options. 

Being denied is not the end of the story. There is no need to pay more than your share. Do all that you can to be treated fairly by your insurance company.