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.
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The way health insurance is being marketed may give you the wrong impression that Nevada Health Link is the ONLY place to buy health insurance these days, but that is NOT the case. You can continue to buy your health insurance from the same agents and agencies you’ve always bought your health insurance from.
Is Health Insurance Worth The Cost?
If you experience a more extensive medical emergency and require hospitalization, hospital bills may quickly become a burden. A three-day stay, for example, could set you back about $60,000 depending on what tests are ordered and what happens during your stay.
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Co-insurance means two parties will be paying for the bill. “Co” means joint, mutual, two, or more. The health insurance company will usually pay the larger amount (example 70%) and you as the member will usually pay the lesser amount (example 30%). This would be considered co-insurance 70/30. This (co-insurance) usually happens AFTER the deductible is met.
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