When A Medical Claim Is Denied

You as the patient go to the health care provider for treatment and expect the health insurance you carry to pay their fair share of the expense. The health care provider gives you the needed treatment and submits the bill (claim) to your health insurance plan. The health insurance plan has a department called utilization review that can refuse (denial of claim) to pay the bill your health care provider submitted for the treatment you received. When you receive notification of a medical claim being denied:

1. Immediately submit the paper work of your plan to appeal the denial.

2. Call the insurance plan and ask for a comprehensive reason this claim has been denied.

3. Contact the medical provider explain you are in the appeal process, request an internal review to determine correct coding, proper ID numbers, and the medical providers submission is correct.

4. Call your insurance agent or benefits representative for help in identifying what is needed to complete the claim payment process. Does the health plan need more information. Has the claim been filed by the medical provider in the accepted time period.

5. Following the above steps can help reveal the claims process error and result in the claim being paid. If the claim is still being challenged you should follow through with the formal appeal process.

6. Write your appeal letter talking about how the treatment resides in the policy of the health care plan. Discuss symptoms leading up to treatment and the consequences or probable outcome of no treatment. Ask your medical providers to submit letters on your behalf.

7. Keep copies of all your correspondence and telephone records.

8. Attend the formal appeal process. This reinforces to the review committee you are a human being and not just the stack of papers they have been looking through.

This is a brief list written to give the reader a sense of the medical claims denial appeal process. Home Care Path www.homecarepath.com encourages seniors to consult with independent council specializing in the appeal process.