If a health insurance company has denied a claim for any medical or dental care received, there are multiple ways to file an appeal. The process can be done by the patient, a professional such as an advocate, or even the doctor may help in some cases. There are also multiple types of appeals to file, including an internal or external review. More information on how to get reimbursed by a health insurance company is below.
When a health insurance company (whether medical or dental) does not pay for what the patient thinks should be covered, the patient has a right/ability to appeal this decision. This in effect means that they will submit a formal request to the insurance provider saying why they think the bills should be paid.
An appeal can be done for a variety of costs. This can include for prescription drugs, dental surgery, hospital bills, pre-existing conditions, and really anything. The dollar amount can vary too. Some health insurance policies may decide not to pay the entire cost of what the doctor charged the patient, so they “underpay” it. Or other companies try to balance bill a person. An appeal can be filed in those instances too if the patient feels they should receive more money.
When tip to help reduce the need for an appeal is as follows. When a surgery is planned, patients should always ask for pre-authorization. This is checking in with the insurance company before the operation is done. This improves communication, and allows a decision to be made in advance before the procedure is completed. If this request is denied than an appeal can be filed.
Patients can appeal almost any decision. Some of the more common disputes are as follows though. But as noted, almost anything can be contested. Common reasons for disputes are as follows:
There may be disagreements over what doctor or hospital is “in network” or not; whether a prescribed treatment is necessary; if a prescription drug is experimental and needed; whether the insurance policy was in effect or not; and many others. Another common appeal may be for pre-existing conditions or not, but this form of dispute should be much less common with the new Obamacare regulations in place.
There are two options for patients. They will be enforced by state laws and regulations. The types include Internal, which is done between the customer and their insurance provider. An External appeal uses an independent, third party to mediate a decision. So the health insurance company is not the one to decide on which bills they will or won't pay. There are pros and cons to each one as well as a different process in place.
Internal appeals – There are very tight deadlines in place. They range from 3 days for urgent care to about 10 days for pre-authorization. The point is do not wait. If the filing deadline is missed then the patient has no possible way to have their claim appealed. A professional, such as an advocate or lawyer, can help with these as well.
First, call the insurance provider to ask them what their process is. There will normally be a form that needs to be completed. There is also often a place to give supporting documentation, such as doctor notes or medical records. Each health insurance company needs to to be transparent on the process and the customer service team needs to answer a consumer's question on how to appeal a denial of benefits.
Some tips on what to file with this form, if needed, include copies of communication with a doctor or insurance company; notes of when phone calls were made on the medical condition; the Explanation of Benefits form; information from a pharmacist on prescription drugs; and more. Be thorough and detailed. Keep copies of all forms and records when filing an internal appeal.
It can be a challenge to keep track of this. Any error in the application can give the insurer reason to deny the claim again. For those needing hands on assistance, an medical bill advocate can help the consumer file all these forms. They will often not charge a fee for their service, but will take a portion of the money saved/reimbursed. Find details on services from medical billing advocates.
Internal appeals should take between 30 to 60 days. This will depend on whether it is pre-authorization or after the fact. Ask this of the company when completing the forms, as they need to provide a time frame of when a decision will be made. It should always be done in writing as well, so the decision should be sent to the patient for their records. If someone does not like the results of it, then they can escalate the process to still file an Eternal Appeal.
Terms of external appeal – The process is very similar to above in that forms need to be completed, the health insurance company must provide details on how to contest the denial of claim, and more. Note that all health insurance providers need to provide their customer with the right to appeal the decision externally. It is required in all 50 sates by the consumer protection boards as well as federal government.
There may be a small cost when taking this external approach. Some states allow the appeal to be through as a free service, others may charge the household a nominal amount that may be around $25 or so. If a lawyer or medical billing advocate is used, they may also charge a minimal fee too. In any case the price is intended to be affordable by people of all income levels.
Many states have their own rules and regulations in place as well. They will regulate insurance companies, operate their own Marketplace exchanges in which low income families can buy policies, and provide other support. Unfortunately it can be difficult to understand these rules. For those that need it, free legal assistance programs are available. Attorneys can help consumers to ensure their legal rights are adhered too.
When needed, the federal government can also help with an external appeal for a denial of claim. The Department of Health and Human Services oversees this process. Their phone number is 1-888-866-6205. They will ensure the patient is treated fairly by a third party mediator. Health and Human Services also has a team of attorneys as well as health care advocate that work with patients on an as needed basis.
No matter what is decided by the external review, all parties need to agree to it. The insurer needs to follow the decision as well as the patient. It can take anywhere from 30 to 60 days to get results, but when they are provided, this is the final say.
Any patient that is denied a claim does have legal rights available to them. These appeal processes are in place to protect consumers. People should never hesitate to use them when needed.
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