What should I do if my claim is denied?
- There are many reasons your claim may have been denied
- Coding errors: If a provider bill for a treatment or procedure that can’t be linked to a particular diagnosis, it will be rejected
- Failure to get prior authorization: Some treatments require the provider to get authorization from your insurance company before. You can appeal this easily since it may be impossible to get pre-approved
- Missing or incorrect information: Missing paperwork and having incorrect information
- Treatment is not covered by your plan: Your policy and level of coverage does not cover the treatment you received
- Treatment is considered medically unnecessary or experimental: They can deny a claim if treatment is not seen as needed to make the patient healthy, and surgeries that correct deformities and looks (such as a nose job, deviated septums, or varicose vein treatment) are often denied. These deformity procedures may be conifers “cosmetic”
- If your claim is denied, you will need to go through the appeal process
- Have all your records in order
- Your doctor can set up a peer-to-peer review that involve your doctor speaking to the insurance company’s doctor (most insurance companies have company medical professionals who determine what is necessary and what is not) to explain the medical necessity of the treatment or procedure
- Keep track of the date. Most insurance companies have a timeline for filing appeals
- If your appeal arrives too late, they can refuse to consider it