Health Insurance Claims Resolving a Dispute in your Favor can be Simple

YOUR MEDICAL INSURANCE CLAIMS HAVE BEEN DENIED
Now what? Take a deep breath. A bit of insight and some busy work will help you resolve most claims disputes much more quickly that you would guess. As an insured, you are party to a legal contract, stating your rights and obligations. If you’re claim is denied, your first step should be to find out from your insurance company’s customer service department the specific reason it was denied.

WHEN YOU CALL YOUR INSURANCE COMPANY’S CUSTOMER SERVIE DEPARTMENT
You should be prepared and armed with a copy of your policy and the paperwork you’ve received telling you the claim has been denied. It’s a good idea to read your policy when you are first covered under the plan. Have a basic understanding of what is covered, what is not and what your responsibilities are. Highlight key areas. Ask questions if you are unclear on key provisions. Ultimately, you will be responsible for medical expenses not covered under your plan. With the high cost of medical care you should be aware of your rights and responsibilities. Keep a folder with information about the claim. Always record details of phone conversations with the insurance company and your provider’s business office.

Claims processing these days is done almost entirely electronically. As long as all flows smoothly, there is almost no human intervention. If necessary information is missing however, or is unclear, the process will come to a screeching halt, resulting in a claim denial or a request for additional information.

Here are some of the most common reasons claims are rejected, and what you can do to turn the rejection into a payment on your behalf.

WERE YOU ACTUALLY ELIGIBLE FOR COVERAGE ON THE DATE THE EXPENSES WERE ACTUALLY INCURRED?
Your insurance policy specifies who is eligible for coverage and when. Eligibility information is collected from enrollment materials: an employee enrollment form or an individual application submitted to the insurance company. Employer sponsored plans have waiting periods before coverage becomes effective. If your date of employment is not listed on the form, claims processing will stop until information is provided regarding when your coverage kicks in. Your enrolled dependents will be eligible until ages specified in the policy or student status. If your dependents’ dates of birth or student status are missing, claims processing will come to a halt until that information is provided.

IS THE CLAIM THE RESULT OF A PRE-EXISTING CONDITION?
Federal legislation requires pre-existing conditions be covered as long as you satisfy conditions of “continuous coverage” which is defined by law. Enrollment forms contain a section detailing your past coverage dates. If information in this area was not provided, claims processing is halted or your claim is denied until the information is supplied. Claims processing software may flag a claim in order to determine if the expenses were the result of an illness or injury that was first treated before you were covered under the plan. If so, a written request will be sent to your doctor asking when you were first treated for this condition. The insurance company’s customer service representative will be able to tell you if they are, in fact, waiting for this additional information from your provider.

DOES THE TREATMENT RECEIVED MAKE SENSE BASED ON YOUR ILLNESS OR INJURY?
Medical claims software is pretty sophisticated. It will match procedure codes with diagnostic codes. If the codes on your bill don’t make sense, the claim processing will come to a halt and either a request for clarification or a denial will be generated. It’s like this: your diagnostic code indicates a bone fracture, but the procedure code indicates a tonsillectomy was performed. The computer becomes confused. Errors like these can occur with the slip of a keystroke in either the doctor’s office or when the claims are entered into the insurance company’s system. A phone call can clear up the confusion and quickly resolve the problem.

ARE THE EXPENSES ACTUALLY THE RESPONSIBILITY OF ANOTHER INSURANCE POLICY?
If your medical expenses are due to an injury on the job or an auto accident, someone else’s policy might be responsible for paying your bills. If so, claims processing will stop and you will receive a request for more information about the circumstances of the injury or illness. As an aside, getting someone else’s insurance to pay for your expenses can only help your future premium increases.

ARE THE MEDICAL EXPENSES ACTUALLY COVERED BY YOUR PLAN?
Some policies don’t cover preventive care. Other times a procedure has not been pre-authorized by the plan, as required (details are outlined in that plan booklet you’ve already read and highlighted). You should know that if your plan uses a Provider Network, those practioners are usually contractually responsible for obtaining pre-authorizations, and in addition, alerting you if suggested procedures will not be covered by the plan. If they goof up and your expenses are not covered by your insurance, their contact with the insurance company-as a preferred provider-may require them to eat those charges.

If you are unable to resolve a situation in which you feel expenses should be covered, contact your HR department for help. Your employer is paying a lot of money for your benefit plan and wants you to be satisfied. You may also enlist the help of the agent or broker who arranged your coverage. Professional agents/brokers are motivated to keep you happy; they want to keep your business. Ultimately, you can contact the Commissioner of Insurance in your state- check the government pages in your phone book. Getting your state insurance regulators involved in your claim disputes generally gets the insurance company’s attention.