Denied Health Insurance Claim? Here Is What to Do Next
If you experience a serious injury or illness, the last thing you want to worry about is high medical bills. Fortunately, if your health insurance company denies coverage for a claim, you have options. A health insurance agent can help you figure out why your claim was denied and whether you have grounds for an appeal. Other reasons for filing an appeal may be that your medication you are taking is not listed as a covered medication or you have hospital bills from an out of network provider. You can file an appeal to get these items covered, however, they are not guaranteed to be approved.
Why Do Claims Get Denied?
Health insurance claims get denied for a myriad of reasons. In some cases, denials result from clerical errors. Maybe your health care provider’s billing staff entered an incorrect code, or maybe the claim was accidentally sent to the wrong health insurance company. Other times, the issue may be related to your coverage limits.
You Have a Right to Appeal Denied Health Insurance Claims
If your health insurance company refuses to cover a claim, you have the right to appeal the decision and have it reviewed by a third party. Your policy should outline how to appeal a denial. In general, there are two levels of an appeal, including an internal appeal and a third-party external review.
Internal Appeal
Your first step for resolving a denied claim is to call your health insurance company and ask that it conducts a full review of the decision.
First, you need to complete all forms required by your health insurance company or send a letter to an insurer explaining the reason for your appeal. You must include your name, health insurance ID number and claim number in this letter. Then, submit any relevant additional information, such as a letter from your doctor explaining why the service is necessary. If you need help filing the appeal, the Consumer Assistance Program in your state can file on your behalf. If you have an agent/broker they can assist you at no cost to you.
You have 180 days from the time your claim was denied to file an internal appeal. If your health situation is urgent, or if the health insurance company stands by its original decision, you can simultaneously file an external review.
External Review
To have your denial handled by a third party, you can file an external review. You must begin this process within four months of the date you receive the final determination from your health insurer that the claim has been denied. Someone else, such as a doctor or health insurance agent, can file an external review on your behalf.
This process may be the best option if your claim was denied because the health insurance company did not believe the service was medically necessary and your doctor disagrees. You may also request an external review if your health insurance canceled your policy because it claims that you provided incorrect information when you first enrolled.
In Nevada, as in all states, health insurance companies are legally required to accept the outcome of the external review.
Nevada Insurance Enrollment Helps You Navigate the Appeals Process
The appeals process can be frustrating, but at Nevada Insurance Enrollment, our health insurance agents can help. We can review why your health insurance claim was denied and help you through the next steps.
Recent Posts
Water / Sewer Backup: Does Homeowners Insurance Cover It?
A standard homeowners insurance policy covers sudden and accidental water damage that comes from inside your home, such as a burst pipe or broken appliance. It also covers water damage that results from rainwater coming in through an opening caused by a named peril.
Is Raising the Speed Limit Worth the Risk?
While vehicles are safer than ever and roadways are engineered to prevent accidents, the fact is that traffic fatalities claim thousands of lives per year. Despite arguments that the majority of posted speed limits are outdated, and unrealistic, numerous crash tests show that higher speeds greatly increase a driver’s risk of serious injury or even death.
Friday Health Plans: Who Are They?
Late last year, Friday Health Plans announced that it was expanding to Nevada and would sell policies on Nevada Health Link, the state’s online Marketplace. These plans may be a good fit for you if you are working within a budget and really like the flexibility of seeing a specialist without having to get a referral from a primary doctor.
Search This Website
Most Popular Pages
By page visits (this month)
#1) Health Insurance Subsidy Chart
#2) Health Insurance
#3) Health Insurance WITH a Subsidy
#4) Insurance Blog
#5) Request a Quote
Top 5 Most Popular
By page visits (this month)
#1) Health Insurance Subsidy Chart
#2) Health Insurance
#3) Health Insurance WITH a Subsidy
#4) Insurance Blog Posts
#5) Request a Quote
Recent Posts
How Much Auto Insurance Coverage Do You Need?
While auto insurance can be pricey, Nevada Insurance Enrollment can help you find the right balance between great insurance coverage and an affordable auto insurance premium. Understanding the options available to you, what coverage you’re required to carry, and evaluating your exposure to risk are good first steps.
Auto Insurance Coverage When Driving in a Different State
Auto insurance coverage can be confusing, largely because insurance laws and requirements vary greatly from one state to another. As a Nevada driver, you’re required to carry liability insurance in the amounts of 25/50/20 (learn more about state minimum coverage here). However, in states like Arizona where coverage runs cheaper, state minimum coverage is a little skimpier.
Health Insurance Plans for Year 2019 and Beyond
According to a recent study, health insurance premiums could increase for individual plans on the ACA marketplace between 35 and 94 percent by 2021. Concern over health care is nothing new; in fact, this is the fifth consecutive year that Americans have ranked health care as a top concern.
Health Insurance Could Become The Wild Wild West Once Again
At least for now, many aspects of ACA are still in place. Currently, an insurer can’t turn you away for a pre-existing condition, and long-term health insurance plans still have to provide coverage for ACA’s 10 essential health care benefits. Prior to 2010, private health insurance usually did not cover maternity, or preventative like it does now, and mental health was generally non-existent.