HEALTH INSURANCE GUIDELINES FOR PATIENTS – WHEN A CLAIM IS DENIED – WHAT TO DO:
INFORMATION BRIEF ON TIPS TO BE AWARE OF REGARDING YOUR HEALTH INSURANCE:
From a Peak Insurance Solutions Insurance Expert:
Read your Summary Plan Description, or your Evidence of Coverage document, if you’re enrolled in an individual health insurance plan or a Medicare Advantage Plan. Many people don’t take the time to read their policies, and miss important information!
If your insurance plan has a network, make sure you know whether the provider you’re seeing is in-network or out-of-network, and what the coverage is.
Certain procedures require pre-authorization prior to undergoing the procedure. Check your insurance plan documents, check with your doctor, and check with the insurance company’s customer service team to ensure you’ve taken the appropriate steps. Doctors, hospitals, and other providers typically initiate the pre-authorization process.
If you’re uncertain, consider requesting a pre-authorization, even if it’s not needed. Make sure you understand exactly what procedure is approved, and when that approval expires, and you need a new pre-authorization.
Some insurance companies require “Step Therapy” for certain prescription drugs. In practice, this means that an insurance company wants to know that if lower-priced drugs that they’ve judged to be equally effective are available to you, that you tried them prior to using the higher cost prescription drugs. If this isn’t an option for you – and it’s not for some cancer patients – your doctor can appeal this to the insurance company and request immediate coverage of the higher priced prescription drug.
The second installment as promised from the August 13th information provided on this subject: Here is the name and number of the health insurance expert who provided the information for everyone:
WHAT STEPS CAN YOU TAKE WHEN YOUR INSURANCE CLAIM IS DENIED?
It’s often distressing when you expect your insurance company will pay a claim, but it is denied in part, or in whole. There are steps you take that help you with a claim:
- You should begin by reviewing your insurance policy (specifically, the Evidence of Coverage document or the Summary Plan Description) to see what the coverage is for your denied claim. If your plan shows the procedure/prescription drug is covered, that gives you a starting point.
- If steps were required prior to the procedure, did you follow those steps (for example, prior authorization, or step therapy)?
- Have you reached any limits imposed by your insurance policy?
- Call your insurance company’s customer service group
- Ask the representative why the claim was denied, and listen closely for the answer. Does the answer match what the Evidence of Coverage or Summary Plan Description says should be covered? If the answer you’re receiving from the representative and the Evidence of Coverage or Summary Plan Description differ, you might want to discuss the discrepancy with the representative, and see if the claim can be reprocessed. Be aware, though, that the representative has limited ability to reverse a claim decision. If you still see that your documentation states the procedure should be covered, you can ask to escalate the issue to a supervisor to see if the claim can be reprocessed.
- Ask the representative for the medical code(s) that was sent by the provider, and ask for a description for that code. Does the code match the procedure you underwent? Medical coding is a highly complex field, and at times, errors can be made by the doctor or hospital who submitted the claim.
- After speaking with the insurance company, contact the billing office of the hospital or doctor’s office. Explain to the billing office that your claim has been denied, and ask them to verify what medical code(s) were used, and if those code(s) are the correct one(s) for your procedure. If there is an error, billing offices are typically quite helpful in changing the code(s) and resubmitting the claim to the insurance company.
- If you still have a claim that’s being denied, the insurance company will have an appeal process which you can undertake to try and obtain a reversal of a claim denial. Be prepared to reference your insurance policy documents, showing that the procedure is a covered one, and that you’ve gone through the proper approval steps, and have not reached any limits. Any other documentation you have which supports your position will also be helpful. Be aware that insurance companies aren’t typically persuaded by your beliefs that a procedure “should be covered,” without supporting documentation.
- If you exhausted all steps above, and still have a claim that’s been denied, you can appeal to your state’s insurance commissioner for a review and decision.
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