If you’ve ever had a claim denied by your insurance company, you may have experienced a feeling of helplessness. These Goliath companies with their maze-like procedures can be daunting to work with. But with the right information, there are ways to get through these “gate keepers” to obtain the care you need.
Here’s a look at common reasons for denied claims and how to appeal them:
Reasons for Denial
According to Becker’s ASC Review, these are the most common reasons for claim denial:
- The patient is not enrolled.
- The procedure is not covered.
- No pre-certification is on file. Insurance companies often require the ASC to receive approval from the carrier before providing medical services. If pre-certification procedures are not followed, the claim may be denied or the payment reduced.
- There is a lack of medical necessity for the procedure.
- No referral is on file. The claim should be filed with a valid referral. If the insurance carrier does not have a valid referral number, the claim will be denied until the referral is provided.
- There are demographic mistakes on the claim. For instance, an incorrect procedure code that is age appropriate would make the claim invalid.
- There is a lack of supporting documentation for claim adjudication.
How to File an Appeal
While every situation is unique and there are often legal implications for which you may want to consult a lawyer, here are the basic steps to filing a grievance or appeal with your insurance company, as shared by eHow.com:
- Obtain a copy of your plan description. If you no longer have the copy you were given when you first enrolled, your employer (if your insurance is through your job) or the insurance provider can provide a copy.
- Review the section outlining the steps and timeline for filing an appeal. It’s important to adhere to every stipulation, or you can lose the appeal.
- Draft your appeal letter. Cite your reason for appealing, medical reasons backing your claim, and medical documentation like test results and a letter from your doctor.
- Send your appeal letter, then follow-up. Be sure to send your appeal letter and anything else outlined in the appeal process by the insurance company within the time frame allotted. When sending your letter, send by certified mail and request a return receipt, so you have proof of when your insurance company received the letter. Then, inquire into the status of your appeal.
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Sources: http://www.ehow.com and http://www.beckersasc.com