Health Insurance Claim Denial And What To Do

Mickey | Financial Services | Sunday, December 26th, 2010

A first reaction of anger or frustration is understandable when opening up an explanation of benefits letter from your private medical insurance company that informs you that your claim for reimbursement of medical expenses is not paid. However, the best next step for you to get the matter resolved is to calm down. Knowing that there are definite next steps you can take to get your claim paid can help you to regain composure to handle this situation.

First, read the letter from your medical insurance company carefully. When a claim is not paid, you will see a zero in the column that indicates the amount your medical plan paid for the services you received. On that same row, you should see a column that contains numbers or letters that are a reference code. Somewhere toward the bottom of your letter you should see the reference for what each code means. (Sometimes you can find this on the back of the letter.)

Now, check the code explanations for medical services where your plan paid nothing. You should get an indication of why the plan did not pay by reading the code explanations. Many times, you will find that your claim has not been denied – meaning the medical insurance company will not pay it. Rather, what you will find is that your medical insurance company needs you to follow-up with some action – usually providing additional information by sending in a form provided to you.

If your claim has actually been denied, then there should be information (usually in small print) provided somewhere on the letter that informs you of how to appeal the denial. Federal and state laws provide that a medical insurance company must have processes in place to conduct an internal review of denied medical insurance claims for those instances when a plan member may choose to appeal a denial.

In summary, many times what appears to be a denial of your health insurance claim is simply your medical plan requesting more information for administrative purposes. Even when your claim is really denied, you have the right to appeal the claim to initiate an internal review by your medical plan provider.

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