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How do I appeal a health insurance claim decision?

Appeal health insurance claim decisionAppealing a health insurance claim decision is not as daunting as it may seem. It will require some time, research, and persistence on your part. You will need the support of your doctor and the assistance of his/her medical staff to be successful in your appeal.

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Be sure to begin the appeals process immediately. Most health insurance claim providers have a limited window of time where they will accept appeals. If you wait until after this span of time to appeal, you will lose your chance for them to reconsider your health insurance claim decision.

The First Step for an Appeal

The first step you will take is to notify your doctor(s) and medical staff that you have been denied. Doctors and their medical staff have extensive experience in these situations. Your medical care provider(s) will be your main advocate when appealing a health insurance claim decision. Their insight and understanding of the appeals process will be of great value to you while you are appealing your health insurance claim decision.

Research your Medical Insurance Coverage

The most common reason for your health insurance provider to deny your procedure or treatment is based on whether or not the specific medical intervention is covered by your plan. Elective surgeries, such as cosmetic surgery, are usually not covered under standard health insurance plans.

Be familiar with your health insurance plan and take the time to read through your provider’s manual before you undergo any medical intervention. If the treatment or procedure is not covered under your medical policy, appealing the decision will be futile.

Is the Procedure Necessary to My Health?

The second main reason for a medical procedure or treatment to be denied is whether or not it is necessary to your health. Health insurance providers may also deny medical intervention if they believe that you are not healthy enough to undergo the treatment or procedure. This is why it is important to inform your doctor as soon as you are denied so that they can contact the health insurance provider and assist you in the appeal process.

Contact your Health Insurance Provider

The next step is to call your health insurance provider and find out what you need to do to appeal their decision. This is called an internal appeal. Every medical health insurance company has their own rules and regulations regarding the appeals process and the steps that you need to take to successfully appeal the decision will differ between providers as well. You should also ask them why you have been denied.

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What your Health Insurance Provider Should Tell You

When your health insurance claim is denied, the company should give you an explicit reason for denial. This should include details of where to find information in your medical insurance policy regarding your specific treatment or procedure. The health insurance company should also give you to the official title and contact information of the company representative responsible for the health insurance claim decision, steps to take to seek alternative medical treatment that is covered by the provider, and an explanation of the health insurance company’s appeals process. If you are not provided with this information, request it in writing.

Make a Record of Your Interactions with the Health Insurance Company

Take notes while you are speaking to them. The information you gather from speaking to their representatives can be an invaluable resource as you undergo the appeals process. You can try to appeal the decision by phone, but often times you will be required to compose a written letter to the provider requesting reconsideration of the health insurance claim decision. The health insurance provider will usually request that your doctor submit supporting medical documents to prove that your treatment or procedure is necessary and/or that you are healthy enough to undergo the procedure.

What to Include in Your Letter

When composing a letter to appeal a health insurance claim decision, make sure it includes your full name and address, date of birth, name of the procedure or treatment that was denied, and your doctor’s full name and address. Include important information such as why your doctor thought it necessary for you to undergo the specific treatment or procedure, why you think it is wrong to have your claim denied, and where in the policy the treatment or procedure is covered. Include supporting documents from your medical provider with your letter.

If Your Medical Insurance Provider Refuses to Reconsider

If you are dissatisfied with the results of your internal appeal, or the process is going too slow, you can initiate an external appeal. This type of appeal involves using an independent review board to examine your case. Usually the external appeal is accomplished by qualified persons who investigate both sides and then make a determination that is final. Both you and the health insurance coverage provider must abide by the board’s decision.

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