Denied Health Insurance Claim? Here Is What to Do Next
If you experience a serious injury or illness, the last thing you want to worry about is high medical bills. Fortunately, if your health insurance company denies coverage for a claim, you have options. A health insurance agent can help you figure out why your claim was denied and whether you have grounds for an appeal. Other reasons for filing an appeal may be that your medication you are taking is not listed as a covered medication or you have hospital bills from an out of network provider. You can file an appeal to get these items covered, however, they are not guaranteed to be approved.
Why Do Claims Get Denied?
Health insurance claims get denied for a myriad of reasons. In some cases, denials result from clerical errors. Maybe your health care provider’s billing staff entered an incorrect code, or maybe the claim was accidentally sent to the wrong health insurance company. Other times, the issue may be related to your coverage limits.
You Have a Right to Appeal Denied Health Insurance Claims
If your health insurance company refuses to cover a claim, you have the right to appeal the decision and have it reviewed by a third party. Your policy should outline how to appeal a denial. In general, there are two levels of an appeal, including an internal appeal and a third-party external review.
Internal Appeal
Your first step for resolving a denied claim is to call your health insurance company and ask that it conducts a full review of the decision.
First, you need to complete all forms required by your health insurance company or send a letter to an insurer explaining the reason for your appeal. You must include your name, health insurance ID number and claim number in this letter. Then, submit any relevant additional information, such as a letter from your doctor explaining why the service is necessary. If you need help filing the appeal, the Consumer Assistance Program in your state can file on your behalf. If you have an agent/broker they can assist you at no cost to you.
You have 180 days from the time your claim was denied to file an internal appeal. If your health situation is urgent, or if the health insurance company stands by its original decision, you can simultaneously file an external review.
External Review
To have your denial handled by a third party, you can file an external review. You must begin this process within four months of the date you receive the final determination from your health insurer that the claim has been denied. Someone else, such as a doctor or health insurance agent, can file an external review on your behalf.
This process may be the best option if your claim was denied because the health insurance company did not believe the service was medically necessary and your doctor disagrees. You may also request an external review if your health insurance canceled your policy because it claims that you provided incorrect information when you first enrolled.
In Nevada, as in all states, health insurance companies are legally required to accept the outcome of the external review.
Nevada Insurance Enrollment Helps You Navigate the Appeals Process
The appeals process can be frustrating, but at Nevada Insurance Enrollment, our health insurance agents can help. We can review why your health insurance claim was denied and help you through the next steps.
Recent Posts
Out of Pocket Maximum
Your out-of-pocket maximum is the most you’ll have to pay for covered services in a policy period (one year), each January 1st it starts over again, and that includes cost of medications too. After you reach this amount, your health insurance plan will pay 100%.
Qualifying Life Event
If you experience a major life change, then such a change is often considered a qualifying life event. Such life events affect your existing health insurance coverage and can make you eligible to change your coverage during the special enrollment period.
What Is A Prescription Drug Deductible?
A prescription deductible is different and separate from the medical deductible, unless otherwise stated. One deductible is for medical, ie: hospitalization, doctors, etc., and the other deductible is for filling your prescriptions.
Search This Website
Most Popular Pages
By page visits (this month)
#1) Health Insurance Subsidy Chart
#2) Health Insurance
#3) Health Insurance WITH a Subsidy
#4) Insurance Blog
#5) Request a Quote
Top 5 Most Popular
By page visits (this month)
#1) Health Insurance Subsidy Chart
#2) Health Insurance
#3) Health Insurance WITH a Subsidy
#4) Insurance Blog Posts
#5) Request a Quote
Recent Posts
Avoid Health Insurance Coverage Gaps When Moving Out of State
If you move out of state, you’ll need to get coverage in your new state and need to report your move within 30 days and enroll into a plan within 60 days, but each state rules may vary. When you move, if you have insurance now, it would be considered a qualifying life event.
What Is the Best Vision Insurance?
Vision insurance is supplemental health insurance that covers vision-related care. This includes annual visits and emergency care, along with corrective products such as glasses and contacts.
When Does Health Insurance Cover Dental Work?
In most cases, dental insurance pays for routine care such as annual x-rays, cleanings and exams, as well as procedures such as fillings, crowns and bridges. Health insurance pays for damage caused by a trauma to the mouth, such as an injury or accident.
What You Need To Know About Health Insurance When Traveling
What happens if you need healthcare services when you are hundreds of miles away from the nearest in-network provider? How you receive emergency or non-emergency medical care and pay for it depends largely on your health insurance plan.