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If you are in the position of having your health insurance claims denied, do not give up without a fight. Although it may feel as if you have reached a complete halt with your
medical insurance provider, do not take their denial as the final word. By following a few simple steps, you may actually stand a good chance of getting properly reimbursed for your medical care.
Fighting Your Denial
- As a member of a health care plan, it is important that you fully educate yourself to get the lay of the land. You need to verse yourself on exactly what your insurance company covers as well as investigate the local laws, as there are state and federal laws in place for how insurance companies need to legally handle complaints and appeals when a health insurance claim has been denied.
- Once you are armed with knowledge, organize your paperwork including your research, the insurance company's Explanation Of Benefits form they sent with your denied claim and a copy of the policy. Call the insurance company, speak professionally and provide all the evidence to make your case. This phone call may do the trick, but it is still important that you take detailed notes regarding the conversation, what was said, whom you spoke to and the date and time of the conversation.
- If verbal communication has failed and your health insurance claim is still being denied, put your complaint in writing. What you need to construct is a "written appeal" of the denied health insurance claim. The best defense is to clearly address the exact cause of denial that was in the Explanation of Benefits letter. For example, if your health insurance claim was denied as it was deemed "unnecessary," then include a copy of your medical records to prove otherwise. Be prompt when filing your denial claim as there is often a cut-off date for when written appeals can be made.
At this time over 43 states have a Patients Bill of Rights when it comes to managing their health insurance. If your claim is still denied, you can request an independent review. According to Parade Magazine, it is important to take the appeal process to the final level: "Although success rates differ from state to state, consumers tend to prevail in these challenges about 50% of the time."
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Health insurance is indeed a blessing, but sometimes it can be a real headache, too, when your health insurance provider denies a claim you've made, or there's some sort of problem with a health insurance claim that you've filed.
The handling of health insurance claims is usually problem-free, but for those times when it's not, you need to know what to do.
Handling health insurance claims works in a few ways.
Option One: The Doctor's Office Submits Claims
The most common method for handling health insurance claims, and far and away the easiest one for health insurance plan members, is that the health insurance claim be submitted directly to the health insurance provider by the doctor or medical facility that you've visited. You simply walk in to your appointment or visit, fill out a form or two, or sometimes just show your health insurance identification card, and then see your doctor or other medical professional. After that you just walk away while the people who work in the doctor's office or medical facility submit a payment claim to the insurance agency.
Option Two: You Submit Claims Directly
A less frequent scenario is one where you have to pay for your visit to a doctor or other medical professional yourself, and then have to submit a health insurance claim to your provider. When this happens you need to have your itemized receipt from the doctor or medical facility which you visited, and then submit it along with your health insurance claim paperwork. It is critical that you have the right paperwork for the health insurance claim that you're making.
If you have any questions about filing a health insurance claim, be sure to consult with a representative of your health insurance provider. They are paid to answer your questions and help you.
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