A major illness or a stay in the hospital can be stressful. It's not a time you want to be worried about your insurance coverage. However, for some insurance consumers, this is when they are hit with a denial – notification their insurance company won't pay all or part of a claim. To help understand your course of action when a claim is denied, the National Association of Insurance Commissioners (NAIC) offers these tips.
Read and Understand Your Policy
What to Do If Your Claim is Denied
In some cases, a simple error could be why your claim was denied. Your provider's billing staff may have entered an incorrect code when your claim was filed with the insurance carrier, or your claim may have inadvertently been sent to the wrong insurance company. This type of error can usually be cleared up quickly with a single phone call.
Keep notes of all conversations you have with company representatives. Include in your notes the name of the person with whom you speak, as well as the date and time of the conversation. Ask for the person's phone extension so you can contact them directly the next time you call. Listen carefully and make note of the answers given to you.
What to Do If Your Insurer Continues to Deny Your Claim
The usual procedure for appealing a claim denial involves submitting a letter to the insurance company requesting that your claim be reconsidered and giving specific reasons why you believe your claim should be paid. When composing your letter, be as detailed as possible; explain why your procedure or medication is necessary and should be paid for under your insurance policy. With your letter, include evidence that supports your claim, such as medical records, x-rays, lab results, or a letter from your physician that explains why the treatment is medically necessary. If you or your doctor feels that the denial of your claim could be life-threatening, you can ask that your appeal be expedited. Keep a copy of everything you send to the insurance company for your records.
The ACA requires that your insurance provider makes its decision regarding your internal appeal within the following timelines after receiving your request:
In response to your letter, your insurance company will indicate the next steps in the process, as well as the timeframe for any additional follow-up or appeals. They may also request additional information from you and/or your medical providers.
You may contact your state insurance department for assistance appealing your claim at any time.
|About the NAIC|
|The National Association of Insurance Commissioners (NAIC) is the U.S. standard-setting and regulatory support organization created and governed by the chief insurance regulators from the 50 states, the District of Columbia and five U.S. territories. Through the NAIC, state insurance regulators establish standards and best practices, conduct peer review, and coordinate their regulatory oversight. NAIC staff supports these efforts and represents the collective views of state regulators domestically and internationally. NAIC members, together with the central resources of the NAIC, form the national system of state-based insurance regulation in the U.S. For consumer
information, visit insureUonline.org.
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