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Insurance companies will have their procedures for handling disputes and appeals included in your policy. These procedures are usually very specific and failure to follow them may result in a denial of your appeal.
How do I dispute my health insurance company denying a claim?
If you receive notice that a claim has been denied you will first need to double check your policy coverage. You will want to make sure that the service you received is in fact covered under your policy. This is especially true if you have a preexisting health condition.
Never rely solely on a customer service representative from the insurance company. They handle many different types of policies and sometimes make a mistake. If a representative tells you something was covered and it actually is not, the company is not obligated to pay due to human error. It is your responsibility to read your policy and understand your coverage.
If you believe the service received is covered by your policy contact the insurance company. Sometimes a health insurance claim may be denied due to an error in billing. It may be that the wrong billing code was used.
Your insurance company will be able to help you figure out why they rejected a service. If it is an error they can give you the information needed to correct the problem. Sometimes it may be as simple as contacting your provider and having them resubmit the claim.
What if my health insurance problem is not resolved?
If you contact the company and your problem is not resolved or you feel there is still an error you will need to file a formal appeal to the company. This will need to be submitted in writing to the insurance company.
You should also send copies of any documentation that supports your claim. Never submit any original documentation in case they get lost and you have to resend them.
The Aroostook Medical Center recommends you start a journal and a file for all correspondence between you and the company. Make sure you request any documents from the health provider as well as the insurance company that pertain to your claim.
Request a written copy of your policy if you have misplaced yours. The Health Insurance Portability and Accountability Act (HIPAA) is a law that requires all health care providers and insurance companies allow you full access to your records and copies if you request them.
You may also need to consult a lawyer to help process your appeal. Remember that you will be required to submit your written appeal within a certain number of days though. For most companies it will be 60 days but you should read your policy to be sure.
What if my problem is not about a claim being denied and cannot be resolved?
Sometimes a problem may arise between you and an insurance company that is not related to the denial of a claim. In some cases, you may be a victim of health insurance fraud.
You may also feel the need to take further action if you file an appeal to only be denied again. If you have contacted the company and a resolution cannot be made you may need to file a formal complaint.
These complaints can be filed with your state’s Department of Insurance. Each state has its own department and they handle hundreds of these complaints a day so it may take a while to hear back from them. Here are some step you should take:
- Check on the status of your claim periodically.
- Submit copies of all documentation you have to support your claim. Any notes from correspondence with the company should be included as well. This will help them get a better picture of your problem.
You can also file a complaint with the Better Business Bureau. They will review your complaint and then forward it to the company. The insurance company will be given 14 days to respond.
While you may not receive any compensation from the company from a complaint filed with the Better Business Bureau your complaint will be logged for three years. These complaints are visible to other consumers researching a company. If the company has been accredited by the BBB it may affect their rating.
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