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Steps to Appealing Healthcare Insurance Claims

/ March 28, 2018

Navigating the healthcare world can be a daunting and complex task.  Have you ever needed to contact the insurance company to get a claim resolved on your own?  The list of road blocks along the way can seem to be never ending: being able to explain your story to someone who is willing to listen, knowing and understanding the terminology, and hoping for a resolution to work in your favor.

In our roles of helping others navigate the system we see mistakes all of the time, from the way that the claims are submitted to mistakes made by the insurance company to understanding exactly how a plan operates.  Many people are unaware of the options that exist when it comes to medical insurance claim denials, and most times the result ends up as an invoice that you are now responsible for satisfying, even if you are not in the wrong. It’s important to know what your options are.

A denied medical insurance claim has a few avenues to travel down, but you must be willing to put up with the battle.  Often times, people are so busy in their everyday life that spending the time to fight a claim is not worth the hassle or the time consumed doing it.  The result: the bill is paid whether it is right, wrong or indifferent at the expense of you, the consumer. The first step in dealing with a denied  medical claim is a first level appeal. This can be handled in verbal form and is your opportunity to tell the insurance carrier your side of the story.  The insurance company can review your explanation to see if liability for the denied claim falls to you.  Although there is no guarantee for the claim to be overturned, it still is worth explaining your side.  If at that time the claim is still denied, then you can approach a second level appeal.  The second level appeal consists of further explaining in depth what took place along with the reason for the first level appeal denial.  As always, this is never a guarantee to get a claim overturned but any attempt is worthwhile.  If at this point the claim is still not overturned, you can submit a final third level appeal to the insurance company.  A third level appeal goes into further detail to get to the bottom of what took place. This is especially significant when liability in fact does not lie on you but you are the one with the invoice that needs to be paid.

While the avenues a claims must travel down to get overturned can take time, the fight is well worth the reward in the end.  Having the patience and knowledge to deal with it is 99% of the battle. If in the end, the third level appeal is not satisfied, then the next step is ultimately filing a complaint with the Department of Insurance.  Filing a complaint with the Department of Insurance can take time.  It takes at least 60-90 days to get assigned for review and another 60-90 days for a decision to be reached, all while the decision may not work in your favor.

Knowing that you have options for navigating the healthcare world is imperative at any expense to you, small or large.  It gives you the opportunity to explain your stance in the complex insurance world. After all, insurance is your opportunity for protection, so protect yourself from being taken advantage of.

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