How to Respond to the Denial of Your Health Claim

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The word “denial” is a tough one to swallow, particularly when it applies to your health insurance claim. However, just because your health insurance carrier denies your claim does not mean you do not have any other options. Here are some helpful tips on how to respond to a claim denial, which could increase your odds of getting a hospital or medical bill paid by your health insurance company.


File an Internal Review

medical_billing_advocate-64You might find it frustrating, with the requirement of acquiring health insurance under the ACA mandate, that you are still left with an unpaid, denied claim. But do not go into panic mode. Every day, countless health insurance claims are denied across the country by health insurance carriers. About a quarter of U.S. healthcare claims get denied every year. Obamacare, as the Affordable Care Act (ACA) is widely known, gives you, the policyholder, the right to appeal a health claim denied by your health insurance company. This means that you can request your health insurance carrier to have the denial overturned.

Your internal appeal can take as long as 30 days or as little as 72 hours, depending on the nature of the original claim. Please note though that this timeline applies only to health plans issued after March 23, 2010. Any plans issued before that date will abide by previous rules.

As per the ACA, your insurance carrier must explain the claim decision within 72 hours for urgent medical situations, and within 15 days if you are seeking a pre-authorization for a procedure. For medical services that have already been done, the window for response is 30 days.

The most common reasons for the original denial of a U.S. healthcare claim are improper coding of the procedure or a medication, care not covered by the specific insurance plan, and/or the medical care was deemed not necessary. Before you apply for the above-explained internal review to your insurance company, be sure to gather all necessary paperwork and fully understand why your health insurance claim was initially denied. This strategy provides you with the best opportunity to fix the issue.


Seek an External Appeal

medical_billing_advocate-110If your health insurance carrier reviews your appeal and continues to deny your claim, then you can appeal to an outside third party. Keep in mind that the external appeal process can be a lengthy one and may be more difficult to deal with when you are recovering from an illness. Only about 5% of Americans pursue the appeal process if their health insurance claim is denied during the internal review process. You have up to 90 days from when you receive the insurer’s denial form to file your external appeal.

Your insurance carrier will notify you of any additional appeal rights that may include the external review process upon their denial of your initial appeal. You will receive details about how to begin the appeal process. For example, the insurance carrier may instruct you to mail a request for appeal to a certain address within a specific amount of time. If your medical situation is an urgent one, you can request for the process to speed up to as soon as 72 hours, which is the fastest time available for the internal review.

The cost for the independent review is free in many cases, except if your insurer requests that an autonomous review board make the decision on your appeal. In the latter case, the fee is usually about $25. It is essential to understand that if you are going forward with the external appeal and your claim is again denied, this is a binding decision. However, close to half of all appeal decisions side in favor of the consumer.

Increase your chances of having your appeal case decided in your favor by having a medical billing advocate on your side. The healthcare system is not an easy one to maneuver, and you likely want to minimize the chances of a second denial that would be irreversible. Contact one of our advocates at Medical Billing Advocates of America for assistance with any denied health insurance claims.

medical_billing_advocate-48When you submit your appeal, be sure to include supportive evidence that relates directly to the reason for the claim denial. If it is a coding error on the original hospital or medical bill, for example, then be certain you have the provider or hospital correct the code and resubmit the claim. Changing a coding error can be very simple and quickly overturned.

As the appeal process starts, retain any paperwork you receive by mail and keep it organized. Also, document any communications by email or phone regarding the appeal or the original claim, and keep them in one location. If you speak with a representative, ask for his or her name. The purpose here is to be able to refer to your detailed notes if there are any issues in the future regarding dates, changes or information you have received.

The initial denial of a health insurance claim is not one that you have to accept. The ACA has guidelines in place that guarantee you the right to pursue a review of the claim denial. By understanding your U.S. consumer healthcare rights, you can make the most of the tools available to you. Doing research and being informed about the ACA can save you money on expensive healthcare procedures or medications that you and your family require. Being cost effective with your medical care and disputing any health insurance claim denials will help all consumers to pay less out of pocket. .

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2 responses to “How to Respond to the Denial of Your Health Claim”

  1. […] from denial of coverage to failure to negotiate a settlement. Under the ACA, a patient has the right to appeal an insurance claim denied by a health insurance company. Under that law, and applicable to any health plans issued after […]

  2. […] Medical Billing Advocates of America offers many services, one of which is helping patients file a strong appeal.  […]