A denied claim is not final; so, take a deep breath, relax, sit down and get a cup of coffee. This article might be just what you need to guide you in finding solutions to your unpaid medical claim.
Gathering of information
Collect all documents that are relevant to your medical claim; such as, you insurance policy, denied claim, letters that you received from your doctor and the insurance company and many more.
Examine and understand the claim rejection reason
Read the claim EOB (Explanation of Benefits) sent by your insurer because you will see there what the rejection reason was. Most of the time a claim will be denied because of the following:
• Errors in submission of claim forms such as the doctor's office failed to use the correct or registered NPI (National Provider Number), incorrect claim form used, wrong place of service used for the procedure, wrong diagnosis code and many more. In cases such as these, the doctor's office only has to file a corrected claim so that your medical claim will be adjusted and paid.
• Denied due to preexisting condition. The insurer will send you a letter requesting for the list of medical providers that you have seen for a specific time frame, so that they can contact your medical providers. Request for your medical records, and the review department will conduct a preexisting review. If they find out that the diagnosis for the medical procedure performed is indeed one of your preexisting conditions that fall under the preexisting waiting period, your claim will receive a final denial. Usually, some claims are pended for preexisting review for months because the insurer is still waiting for the response of the member to the letter of the request or for the medical records.
• Denied due to precertification. This means to say that the medical service performed is a covered service; however, approval should be obtained before it can be performed. The facility or doctor's office has to call the precertification department of the insurance company before performing the service. Usually, services that require approval are 24 hours inpatient stays, expensive diagnostic services such as MRI and CAT scans, mental health services and expensive durable medical equipments. If for some reason no precertification was obtained for the procedure or equipment, your medical provider can call the precertification department and get a retroactive precertification and re-file the claim.
• Denied due to no predetermination. It is a procedure where a medical provider with the member's request/approval would send the insurer the member patient's medical records and recommended medical tests, medical equipments and treatments for non-emergency procedures that are usually very expensive such as breast reconstruction and bariatric surgery.
• Denied due to timely filing. Claim timely filing limits vary depending if the medical procedure was performed by a non-contracted provider and which state you are located. Usually it is six months from that the date of service. It could be that your medical provider sent the claim before the timely filing limit, there was a computer glitch in the insurer's system, and they only received the refilled claim. So, do take the time to speak to your provider and know when was the first time they filed the claim. You can request them to re-file the claim if they can show a copy or proof of timely filing.
• Denied due to eligibility. This usually happens to newborn babies who are not yet added to the policy. Just call your insurance representative and have the claim adjusted over the phone. A newborn is covered under the mother's policy for the first 30 days from birth for most states.
• Denied due to COB (coordination of benefits). If you have another insurer as your primary insurer, your claim needs to be filed to the primary insurer first, and a copy of the EOB should be sent to the secondary insurer so that you claim will be processed.
Contact the insurance company
Now that you know and understand why the claim was rejected take note of the information that you will need such as your insurance account number, reference numbers of precertification or predetermination, the date the claim was originally filed, medical records and anything that is relevant to your claim issue. Call your insurance customer representative (it will take time to reach a live agent, so stay cool). Talk to the insurance representative about your claim issue; why you think it is incorrect, and give your supporting information clearly. Request that your claim be reviewed or adjusted. Always ask for the number of days that you are to wait before it will be resolved and you can call back for a follow-up. Also, ask for a call reference number so that when you call back to follow-up your claim, you only have to give your call reference number to the next representative who receives your call, and she or he will be able to pull up your account records and documentation right away. This will help you save time and service will be fast and easy.
Do record your conversation with the representative. Get his employee ID number, and also document the time and date that you called. Take down notes of the things that you talked about during the call.
File an appeal to the grievance department
If still your claim issue is not resolved, you may file an appeal. You may either do it by writing to the insurance grievance department or you may fax it. There is a timely filing date for appeals and it all depends to what state you are in. Just ask you broker. You may call your insurance representative and ask for the requirements for filing an appeal, the timely filing limit and address.
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