By Kandy

Unfortunately the majority of us have had the experience of an insurance claim being denied. As a patient it can be quite mind boggling and extremely frustrating when you aren’t sure how to proceed. From my own past experiences, I understand that the process of “jumping through the hoops” to satisfy your insurance provider can be very aggravating; I hope that the following suggestions will be able to give you a better understanding of the initial steps of insurance appeal.

• If you have any questions on your policy benefits, I highly suggest you refresh your memory and read your policy thoroughly. I understand it’s not the novel of the century, but we, as the insured, are responsible for knowing our benefits. If you do not understand the benefits, call and speak with the customer service insurance representative and ask questions until you have a full understanding of the benefit coverage and policy limitations.

• Once you are in receipt of the explanation of benefits (EOB) that specifically states your claim is being rejected or denied, you have the right to request an appeal (or review) be performed by your insurance carrier. You may also want to contact the healthcare provider office where services were performed and inquire as to whether or not they have received a denial and what steps may have been taken in the process of getting your claim paid.

• Retrieve the documentation that you have on being referred, or the pre-certification information for the service performed. Secondly, request copies of all documentation that relates to the denied claim, whether it is office notes, surgical reports, diagnostic test results, etc. Then organize accordingly as this will be needed during your conversations and correspondence with your insurance provider.

• You can generally make initial contact to your insurance provider with a telephone call to the customer service department to request that a detailed explanation of the denial be reviewed with you. It is of extreme importance that every detail be documented, including the date & time of your call, whom you spoke with, and every detail of the discussion. This process will allow you to track each and every contact that is made whether with the insurance provider, the healthcare provider, or practitioner involved in the case.

• Inquire how to start the appeals process, as some insurance companies start with an informal appeal that is completed over the phone. (This is where your organized notes come in handy as you “bare the burden” of proving necessity of the performed service.) This is when you state “your case” and “prove” that the procedure, test, etc. was necessary, why it was performed, or why you had to go out of the approved network area for services. If a phone appeal is not allowed, then follow the steps the insurance company gives you. Copy all mailed correspondence and mail it certified mail with return receipt requested so that you have documentation of this correspondence also.

I cannot stress enough the importance of writing each and every detail down no matter how insignificant it may seem; after all, the insurance/customer service representative is notating every aspect of the call on his/her end, he/she may even be recording your call as is routine practice in the majority of instances, to avoid a “he said – she said” situation. The recorded call can be retrieved at any later date should it be needed. This is the insurance companies “proof” of what was said, agreed to, denied, or admitted to, etc.

• When you are speaking to the customer service insurance representative ask him/her to repeat their answer in terms that you are comfortable with. Write down their answer and then repeat it back to them so that you have a clear understanding of the answer. If you are not satisfied, ask the representative to please repeat it until you understand it.

• Usually, once the initial appeal process has been submitted, the insurance provider will inform you of how many days it will take for a review and response from them. If you have not received a response within the allotted time frame, call them again and inquire as to the hold-up on processing your claim. If a time frame is not given ask the representative to tell you how long the process of review is anticipated to take, and document, document, document.

• Should another EOB arrive that denies payment, request that your physician write an appeal letter notating the medical necessity and relevance of the procedure. Ask your physician to please send you a copy of all correspondence s/he has with the insurance provider.

• If a third denial should arrival and you feel that this claim should be paid, then you may be able to receive assistance from your state’s Department of Insurance also called the Department of Manage Care. You usually have a 50 – 50 chance of winning at this appeal as an independent panel of physicians performs this review.  However, if you are insured by a self-funded plan they may not be subject to state regulation and an appeal at the federal level may be necessary. In this case you would contact the Department of Pension & Welfare Benefits Administration. You have a chance here too of winning especially if the review panel finds any inconsistencies in payment that were made for other claims on the same plans.

This information is in no way a substitute for an appeal, nor does it explain individual insurance policy benefits. It is for informative purposes only and thorough research of your individual policy and guidelines should always be your first line of information. I hope that you find the information in this article to be of some use should you ever have the need to file an appeal.

There is a large amount of information on the internet about how to file an insurance appeal. For more information the following articles may be of interest to you also:

http://www.online-health-insurance.com/health-insurance-resources

http://www.ec-online.net/knowledge/Articles/meddenials.html

http://www.revolutionhealth.com/insurance/information