So, your claim has been denied, and there's a huge bill waiting to be paid. Claims can be rejected because the plan doesn't cover the procedure, medication or supply, or because the insurance company deems it medically unnecessary or experimental. If you think you've taken all the measures to avoid a rejected claim -- like calling the insurance company before the visit or thoroughly reviewing your policy -- you can try and turn the denial to acceptance.
If a claim is denied for any reason, including administrative error on the part of the insurance company, a quick phone call could solve the problem. If this doesn't work, you can request a formal review by the insurance provider. You must resubmit your claim, which is reviewed by a health care professional who specializes in the field in which the procedure or medication belongs.
We must note here that you usually have to go through with these formal reviews within a strict time line. If your formal request is denied, there is one more effort that could pay off. Each state has its own department of insurance that works to ensure that consumers are protected and that the regulatory processes of the insurance companies are fair. So, a call to your state's insurance department might help.
For more information about health insurance claims, check out the links below.
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More Great Links
- Insure.com: How to Avoid a Health Insurance Claim Denial. http://www.insure.com/articles/healthinsurance/claim-denial.html
- American Medical Billing Association. http://www.ambanet.net/AMBA.htm
- Dept. of Veteran Affairs: Rejected Claims. http://www.va.gov/hac/forbeneficiaries/champva/rejected_claims.asp
- POA: Your Duties After a Loss. http://www.policyholdersofamerica.org/policyholder.html