Insurance Part 2: How to appeal a claim

[dwallyfam]

Here are some tips to appeal your claim if you believe it should be paid.

1. Double check to see if the Drs. office coded the procedure correctly. The insurance billing people are coding hundreds of claims a day. Typos do occur. Also, most claims are either sent in electronically or scanned. Computers do make mistakes as well.

2. Call the insurance company and find out the specific reason for denial. It could be that something wasn't sent in. State laws require all claims to be paid or denied within a certain period of time. If they don't receive the requested items they will deny the claim.

3. Call your benefits person at work. They sometimes can ask that claims be considered as a one time exception by the insurance company. Also this gives them some leverage at renewal time to ask for premium relief it there are lots of problems.

4. If you do need to do a formal appeal with the insurance company make sure that you
a. fill out the proper paperwork. Some states require that appeals be filled out on certain forms.
b. be specific as possible as to why it needs to be paid. You wouldn't believe the number of letters I see that state "Just pay this". The more information, and documentation the better off you are.

5. If you have to appeal to the state find out which department handles this. Depending on how the company pays the premium depends on who you have to go to. Most of the time it will be the insurance commission, but sometimes it is the department of labor. If you have union benefits sometimes it goes to the union board. Some states have a third party insurance arbitrator that handles these. Check your policy for this information. Also check for paperwork that needs to be filled out. I know Arizona has certain forms that have to be filled out to appeal., if you don't send in the forms it is a automatic denial. Send in all applicable documentation(copy) with this as well.

6. If you skip of steps 1-4 and go straight to 5 there are some states that will not authorize any payment, even if you are entitled to it because you skipped over due process. Arizona being one of those.

I hope these help everyone in the states with their insurance. If you have any other questions let me know.

Kellie

[Pepper]

Thanks Kellie