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  • Health procedures insurance companies won’t cover
  • January 16, 2014
  • How to fight a claim denial

    So what do you do if your insurance company declines to pay for a medical procedure, service or medication? There are several courses of action, but the first is to appeal or challenge the insurer’s decision, says Susan Pisano, a spokesperson for America’s Health Insurance Plans, a national trade association representing the health insurance industry.

    “Ask them to reconsider,” Pisano says. “The process for how to do that is usually detailed by your insurance company in a letter when the service is denied.”

    The Department of Labor mandates that all insurance plans have an appeals process and they must legally disclose your right to appeal when a claim is denied. That disclosure is generally found in the summary plan description.

    To appeal a claim denial, generally, you should write a letter to your insurance company appealing the denial and giving specific reasons why you think your claim should be paid. The letter should be as detailed as possible. It should explain why your procedure or medication is necessary and should be paid for under your insurance policy. You should also request any evidence, including medical records, X-rays and lab results, in support of your claim and send them along with your appeal letter. Be sure and keep a copy of everything you send to the insurance company for your records. You typically have at least 180 days to file an appeal, but check your plan to see if it calls for quicker deadline. Reviewing your appeal can take between 72 hours and 60 days, depending on the type of claim. Your insurer must send you a written notice, telling you whether the appeal was granted or denied.

    If the company upholds its denial, Pisano says there’s the potential for an “external review.”

    “External reviews are typically handled by people who don’t have anything to do with the health plan,” she says, adding that they are usually conducted by unbiased physicians selected by nationally accredited independent review organizations and approved by the state’s department of insurance.

    While specific procedures may vary state to state, here’s how the external review process works in Illinois. Your insurance company will provide a form for you to submit a written request for an external review. In urgent cases, you may also file a request over the telephone. A request for an external review must be filed within four months after you to receive notice from your insurance company that the treatment recommended or provided by your doctor has been denied. Once you submit a request for an external review, your insurance company has five business days to determine if your request is eligible. The health insurance company also picks up the tab for an external appeal.

    If your insurance company determines that your request is ineligible for an external review, the company must provide a written explanation of why your request is being denied within one business day. If that happens, you can appeal your insurance company’s decision by filing a complaint with the state department of insurance. You can also ask that your state’s insurance commissioner review the appeal. Just remember that not all health plans are the same and the process may vary, so be sure to check with your state’s department of insurance for specifics.

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  • Category: Health Insurance

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