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
Hidden Pitfalls of Cheap Auto Insurance
Car accidents can be expensive, and your auto insurance policy is your best protection against financial devastation if the unexpected happens. While state-minimum coverage is definitely better than no coverage at all, a high percentage of scenarios shows it’s not enough for most drivers.
How Financing Your Car Affects the Insurance Premium
However, you may end up paying a higher premium than someone who has not financed their vehicle. If you make payments on your vehicle, your lender requires you to have comprehensive and collision coverage on top of the state minimum requirements.
Adding Uninsured / Underinsured Motorist To Your Policy
Uninsured and underinsured motorist coverage is used when you are hit by a driver that has insufficient coverage or no coverage at all. This optional coverage helps to compensate you for damages, up to your policy limit.
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
I Witnessed A Car Accident; What Do I Do?
A car accident can happen in the blink of an eye and witnessing one can be scary. After an auto accident, all drivers involved are required to stay at the scene where information is exchanged for auto insurance purposes. But what should you do if you witness a car wreck?
Accidents / Vandalism: Does Auto Insurance Cover Personal Belongings?
Personal items such as a tablet, wallet, or any personal valuables are not generally covered in your auto insurance policy. Those items would be covered in your homeowners/renters policy. You would have a deductible to pay for first, and then you’d need to consider the consequences of a claim on your homeowners policy.
Windshield / Glass Coverage
Windshield / glass coverage pays the amount of a covered glass loss, and as an added perk, it has a low deductible. Your insurer will cover the full costs of the repairs up to your policy limit, and as long as the costs of the damages don’t exceed your coverage limit, you’ll pay only your small deductible.
Term Life Insurance vs. Whole Life Insurance
Term life insurance policies will often have terms of one year to 30 years. Typically, the monthly premium (monthly payment) stays the same throughout the term of the policy. Whole life insurance provides coverage your whole life and it includes something called “cash value”. Think of it like a mini savings account attached to the policy.