- Keep all documents with dates of service (very important to have exact dates), providers’ names, Explanation of Benefits (EOBs), and other invoices from the doctor handy.
- Make your doctor your partner in the process. If a claim was denied because you have to prove a procedure is medically necessary, you will need your doctor to make a strong case for you.
- Keep calm. This process can be stressful, but there are good avenues available to help get to a resolution.
How long is too long without getting a response to a claim?
Your insurer must notify you in writing within 15 days if you’re seeking prior authorization treatment, within 30 days for medical services already received, and within 72 hours for urgent care cases.
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How can I deal effectively with repeated rejected claims?
There are ways to appeal with the insurance company (internally) and then ways to involve the state insurance department if you don’t get to a resolution.
To file an internal appeal you need to do the following:
- Complete all forms required by your health insurer, or you can write to your insurer with your name, claim number, and health insurance ID number.
- Submit any additional information that you want the insurer to consider, such as a letter from the doctor.
The Consumer Assistance Program in your state can file an appeal for you.
You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied. If you have an urgent health situation, you can ask for an external review at the same time as your internal appeal.
If your insurance company still denies your claim, you can file for an external review.
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What can I do to ensure my claims aren't rejected the first time I submit them—is there any special documentation needed from the doctor?
First, let’s understand common reasons for a denial:
1. If it is a complex or special medical procedure that needs to be performed, first check the policy on whether the procedure needs a prior approval from the insurance company. If so, then your doctor can help get that, as she would explain the medical need for the procedure.
2. The other reason for denial is that the doctor performing the service is “not in the network.” To prevent this, check with your physician every time you see him whether he still accepts your insurance plan (show insurance card). It is possible that the doctor’s status with the insurance changes within the year.
3. You received a service beyond what is covered—for example, you got a mammogram less than 365 days before the last one. This preventive service is allowed annually. They count the full year between services, not just the actual calendar year when the service was performed.
If you’ve been diligent about the above, it is essential that you complete the claims form fully and attach the statement from the doctor to indicate you’ve received the procedure. Keep copies of all submitted, so that you can refer back to them.
How important is persistence with dealing with insurance claims, and do you have any advice to help me not feel discouraged when trying to get a claim approved?
Both persistence and patience are essential. When speaking to claims representatives, get their names and direct phone numbers so you can reach them again, if needed, and you can ask to speak to their supervisor. You can ask for the documentation stating the exact policy, and loop in your doctor’s office if there is information they can provide that is helpful to getting the claim approved.
Is there ever a point when I should just accept that my claim will never go through, or will a claim eventually go through if I try hard enough?
If you try and still don’t get to a resolution, there are public advocates to help. Or, there are paid services you can hire—medical billing experts who can help you with the claim denial.
For more information you can visit, healthcare.gov/appeal.
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