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How to Appeal a Denied Health Insurance Claim
How to get health insurance claims approved

Dealing with insurance red tape adds complications no one wants when facing a health issue. To receive a denial on your insurance claim, even after you’re feeling better, can be exceptionally frustrating. To help avoid unwanted stress on your finances and your peace of mind, consider the following methods to appeal a denied health insurance claim.

Denied why?

Determining the correct course of action when faced with a claim rejection starts with figuring out why it was denied in the first place. According to Healthcare.gov, claims can be denied because what you want covered isn’t outlined under your current plan, the benefit was deemed “not medically necessary,” “investigative” or “experimental,” your condition is considered pre-existing, the insurance company suspects you of fraud or you and your insurance company just don’t agree.

When faced with a denied insurance claim, you can fight the decision with an internal appeal, an external review or both if your claim is denied after the internal appeal process, according to Bankrate writer Sarah Berger.

Internal appeal

Berger reported there is a small window — 180 days — open to an internal appeal that starts when your insurance sends you its denial. To get the internal appeal process rolling, you’ll need to find out what forms, paperwork or doctor’s statements are required by your insurance provider. Whatever paperwork you submit or fill out, Berger recommends making copies for your records. If you’ve already received the claimed treatment or service, you have to hear a response from your carrier within 60 days, or 30 days if you’re waiting on the treatment, according to Heathcare.gov.

External review

By launching an external review, you’re opting to get the opinion of a third party. If the external review says the denied claim was unjustified, your insurance company must approve your claim, as stated by Healthcare.gov.

“Your external review is the last step you can take, and whether the outside party decides to either uphold the insurance company’s denial of your claim or reverse it, your insurer must accept it,” writes Berger.

Once you receive notice from your insurance company that your claim has been denied, you have only 60 days to seek intervention from an external review, according to Healthcare.gov. Make sure to check your insurance company’s policy on external reviews, as you might earn extra time to start the process. But, it’s always best to start the process as soon as you can.

Once you’ve filed the paperwork necessary for an external review, a decision must be made within 60 days. A fee of approximately $25 may be assessed if your insurance company uses a state external review process or an independent review company or organization to fulfill the review. Healthcare.gov writes that you won’t pay anything if your insurance company enlists the U.S. Department of Health and Human Services protocol to facilitate the review.

The Department of Insurance and Consumer Assistance Program are helpful resources when appealing a denied claim, notes Healthcare.gov.

A denial from your insurance company doesn’t have to be the final word on your claim. You have the right to know why your health insurance claim wasn’t approved, and thankfully, with internal appeal and external review processes, you have methods to reverse a denial.



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Published by East Boston Savings Bank
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All content contained in this newsletter is for informational purposes only and should not be relied upon to make any financial, accounting, tax, legal or other related decisions. Each person must consider his or her objectives, risk tolerances and level of comfort when making financial decisions and should consult a competent professional advisor prior to making any such decisions. Any opinions expressed through the content in this newsletter are the opinions of the particular author only.  


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