Benefits

Five Steps You Can Take if Your Health Insurance Claim is Denied

August 14, 2019

It can be worth the effort to advocate for yourself should your health insurer unexpectedly deny a claim to pay for a medical treatment or procedure. In this post, we provide helpful steps you can take in the event you receive a claim denial.

1. Verify that the expense is eligible

If your claim is denied, it is a good idea to first assess your claim and verify that the care or treatment you received was, indeed, a covered expense under your insurance. You can call the insurance company for more information. Another option is to locate the certificate of coverage for your insurer, which will provide a detailed description of what is and is not covered by your plan. The certificate of coverage can usually be found on your plan carrier’s website.

2. Rule out a clerical error

If you’ve checked your insurer’s certificate of coverage and are certain your expense is one that should have been covered, the next step is to make sure your denial isn’t due to a clerical error. Generally, claims are processed electronically. If your claim has failed to go through the first time, the reason could be something as simple as a missing code or an incorrect date of service. Sometimes, the doctor or facility who treated you will see the denial on the claim, then will look into the reason and resolve it. If your claim is denied, it’s usually a good idea to check with your healthcare provider first to see if they have already resolved the issue and resubmitted the claim. If, however, the claim is administratively correct, there could be some additional information required to get the claim processed.

3. Make sure to provide enough information

Insurance carriers have guidelines that they use to decide if they will cover a claim or not. If your claim is denied, it could be that your healthcare provider didn’t provide enough information to demonstrate that the service was medical necessity. In this case, you can work with your doctor’s office to help provide as much information as possible to show your insurance carrier that your claim falls within the guidelines they have set to pay for services.

4. File an appeal

If you are convinced that your claim should be covered by your insurance carrier, based on the provisions of your policy, and you have verified there are no clerical errors and that adequate information was provided about your health issue and treatment, then you may decide to file an appeal.

The following are guidelines for the appeal process:

  • Check your insurer’s certificate of coverage for more information on the appeals process. Again, this is usually posted on your carrier’s website or you can call the carrier and request a copy.

  • Keep a specific file or folder to track your claims. Make sure it includes all information, including:
    • A copy of all “explanation of benefits” statements from your carrier.
    • Itemized receipts from the service provider or facility.
    • Copies of any correspondence related to the claim.
    • Detailed record of all your attempts to resolve the issue.
  • Write down everything that takes place in each call as part of the process of working to get your claim paid. This includes:
    • The number(s) you call.
    • Date and time of each call.
    • Name, title and location of the person you speak to.
    • Details of what was discussed on each call.

Once you have gathered all the pertinent information, you will want to file an appeal. The appeal should be in writing and include:

  • An appeal letter stating your case.
  • A letter from your doctor addressing the specifics of your treatment.
  • Any pertinent information from your medical records, such as history of treatment, similar treatments you’ve had that were covered and documentation of office visits or hospital care due to the issue.
  • Any articles from peer-reviewed clinical journals that support medical efficacy for the services rendered.

The following tips can help you strengthen your case:

  • Stick to the facts. Be sure to include any relevant information that supports your claim.
  • Use language from your insurer’s certificate of coverage when you can and cite the page number where you found the information.
  • Try to remove all emotions from your case. It may be helpful to write out your case and then set it aside for 24 hours, allowing your emotions to settle. Then re-read it and make changes as necessary.
  • Ask a friend or family member to review your case before you submit it. They can help point out any possible improvements or specific areas that aren’t clear.

5. If your appeal is denied

Under the Affordable Care Act, insurance carriers are required to comply with a standardized internal and external review process. Insurance carriers must explain why a claim has been denied. Consumers have the right to appeal to the insurance company. This usually starts with an internal process in which the carrier conducts a full and fair review of the decision. Consumers also have the right to request an independent third party review the claim if the carrier’s internal review still leaves it in dispute.

While the claims appeal process can be arduous, employees can prevail. Your HR representative can be a great ally and direct you to where to find relevant coverage information in advance so that you have a better understanding of how your benefits work.

This communication is for informational purposes only; it is not legal, tax or accounting advice; and is not an offer to sell, buy or procure insurance.

This post may contain hyperlinks to websites operated by parties other than TriNet. Such hyperlinks are provided for reference only. TriNet does not control such websites and is not responsible for their content. Inclusion of such hyperlinks on TriNet.com does not necessarily imply any endorsement of the material on such websites or association with their operators.

By Janice Scherwitz

Janice Scherwitz is a benefits compliance analyst at TriNet.

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