It can be emotional and frustrating if your health insurance claim is rejected. Thankfully, there is an opportunity to appeal the claim and even legal options for you if your claim is rejected. A claim, procedure, prescription, or test can be denied for a number of reasons. Here’s what our experts recommend if you have a rejected health insurance claim.
First, find out if the claim was denied or rejected. You do not need to appeal the claim if it was rejected. A rejected claim means that the claim has been filed with incorrect information, or a mistake was made by a claims agent. If you have a rejected claim, all you need to do is resubmit the claim with the correct information. When revisiting your claim, look out for:
- Any incomplete/incorrect information, misspellings, or billing errors
- Your health insurance plan covers the claim
- That you’re still within your insurance limits
- Your claim is with a healthcare professional within your network
- Any products paid for by insurance aren’t replaced due to ill-care
If you’re having trouble finding the problem with your rejected claim, ask your insurance provider what’s missing from the report.
The first thing you need to do if your claim was denied is find out why. If your claim was denied, your insurance company will send a letter with an explanation about the denied claim, and why it was denied. Finding out why the claim was denied before you appeal the claim will also let you know if there was a filing or clerical mistake by your claims agent. It’s also important that you understand why the claim was denied so that your insurance company will review the appeal more quickly. Ask your insurance company how they prefer to go about their appeal process to ensure you are reimbursed in a tactful manner.
Be sure to check that your claim was made in your network and that you haven’t gone over any of your limits. In the future, be sure to double check that all healthcare visits are within your network and coverage. If you have gone over your limit, you can negotiate an out-of-pocket payment plan with your insurance company.
Go Over Your Policy
Next, go over your policy and highlight everything that may be relevant to your claim. Working with a lawyer can also help you know what’s covered. Write down everything that is covered by your insurance, and make copies of the policy with your annotations. Your insurance company is obligated to ensure you understand everything that is and isn’t covered. Note anything that seems too vague and ambiguous, then talk with your lawyer about the implications of those statements. If your insurance company has not answered all questions regarding your policy truthfully and honestly, they cannot reject the claim. Send one of the annotated copies in your letter of appeal, and keep one for your records.
Making the Appeal
Find out the claims agent handling your case, or call your insurance company’s claims department. Speak with them about who needs to be addressed in your appeal and how long the appeal process normally takes. A lawyer can also help you write your appeal letter. In your letter, be sure to include the following:
- An opening statement with your policy number and claim
- All rejected claims and evidence related to it
- An explanation with your health history, medical conditions, and why these procedures are essential for you
- Your annotated policy with a list of everything that should be covered
- Supporting evidence from your healthcare professionals and doctors as to why this procedure is vital for your treatment
Make sure to have several copies of the appeal letter for you and your lawyer. Having a lawyer help you write the appeal letter will also ensure that everything is accurately covered.
Taking Legal Action
If your insurance company replies with a vague or unclear response regarding the terms of your policy, contact a lawyer if you have not already. Insurance companies must be truthful and honest about their policies. A lawyer can help you navigate all the falsities and failures of your insurance company. To get free legal advice on insurance appeals and denied claims, talk to one of our Premier Partners about what you can do.