Going through the blog by revenuexl.com, you will come across some comments about people who are denied their insurance refunds for their claims. There are times when you will need to fight for your rights when claiming for your health insurance. Your claim might be denied for a reason which is valid. Before you go ahead and appeal the decision, you will need to, first of all, find out why in the first place, it was denied.
There are some health insurance claims which end up being denied due to how it was entered which mostly is a mistake committed by the claim processing agent or that there was information that was missing. All the health insurers have processes for appeals that allow members to contest a claim which is denied. If you have the know-how on how to fight for your claim that has been denied, you might get the claim through the process of appeal.
The difference between the rejected claims and denied claims
A denied health insurance claim is when the insurance company doesn’t approve payment for a certain claim. In such a scenario, the insurer decides that it is not going to pay for a certain prescription, test, and procedure.
In case it is rejected, it doesn’t get processed because the information when submitting the claim form was incorrect. A claim which is rejected doesn’t have to be appealed. All you will have to do is to correct the information and resubmit it to the insurance company for processing purposes.
Reasons why health insurance claims might be denied
When you know why there was denial on your claim on health insurance, it is very important as it will help you when you are making your appeal decision. In case your appeal goes through, the company will have to pay for it even though in the first place it was denied.
The following are some of the reasons why your health insurance claim might be denied:
- You have missing or incomplete information in the forms which were submitted or there might be a medical billing error
- Your medical plan might not be covering what you are trying to claim or the procedure might be considered not to be medically necessary
- You might have exceeded the coverage limits for your plan
- The therapy or drug is off-formulary and out of your medical plan
- You might have used an out of service network or utilized an out of state health insurance while your health plan requires you to use in-network providers.
How to fight for a health insurance claim decision
First, you will receive a notice for denial of your claim to the health insurance. The notice will have details as to the duration with in which you can appeal the decision which is important to ensure that you don’t miss on your deadline.
Before you start on your appeal, find out the reason as to why your claim was denied. To appeal for denial doesn’t all the time makes sense when your plans or services you are claiming for are not covered, you were out of the covered network, or you have already exceeded the limit of your plan.
If you are not sure, then you should first of all check out on your health insurer’s website or give them a call so that you understand the policies in regard to the coverage and the reasons behind your denial.
Write an appeal letter to fight your claim denial.
When you write an appeal letter for your claim appeal denial to your insurer, it means you are trying to communicate the information which is the correct one so that your case is re-evaluated within the shortest possible time.
If you go ahead and request an appeal and yet you are not sure why in the first place your claim was denied, it might be difficult for the insurance company to review your appeal. There is a need for you to first of all talk to the company where you insured so that you find out the reason why you were denied and how their appeal process works.
To avoid your appeal being delayed, you will need to follow the procedures for the appeal as per their policies and send the information which they requested to the right person or the right department.
Contents of your appeal letter
The appeal for your claim letter should include the following:
- Opening statement
- History and explanation of your health problems or medical conditions
- The information which supports your claim from your doctor
You will then send your appeal within the stipulated time limits via a mail that is certified so that you remain with proof that, for sure, you did submit your request on time. Understand your coverage and why your claim was denied as those are the key information.