What To Do If Your Health Claim Is Denied

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Your Health Magazine

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What To Do If Your Health Claim Is Denied

Health insurance is a crucial option that gives you security in your life. 

Everyone applies for the insurance to get benefited and ensure the safety in case of any mishap. But sometimes the situation turns around and your health insurance claim is put in denial. In this stance, juggling with the denial reasons, appealing process, and making documents can be quite hectic and stressful. 

This article will guide you to put your efforts in the right direction to obtain a successful outcome, ensuring a best opportunity for a success in appeal as well.

Following are the steps to take action about in a sequence:

Decode The Actual Reasons For Your Insurance Denial

Insurance companies are responsible for giving statements about their result of denial in an explanation of Benefits(EOB). The first step is decoding the actual reasoning behind the denial, which makes your process much easier and smoother in resolving the problem effectively. 

You may identify the common reasons for this, which may be the following:

• You may have submitted an incomplete form of insurance.
• Your policy may not include the therapy you are filing for.
• The treatment for which you’re applying may need pre-authorization from the company.
• The last could be that the medical professional does not consider the treatment suitable for insurance.

Examine Your Policy Of Insurance.

This commonly happens when a person hasn’t even read their insurance policies carefully.

Next step is to look for the policy considerations you have. Review the complete insurance policies especially the part where reasons of denial is defined.

By knowing the insides of the policy to put your arguments effectively, such as:

• Coverage of the denial service in policy
• Need of pre-authorization from the company
• Any special conditions, i.e., exclusion applied.

Set Up All Corresponding Documents For Appeal.

Documentation is an important part of every case. Obtain all the documents and make a file to apply for the appeal of denial, which includes:

A comprehensive record of all the medical treatment and diagnosis reports of ailment.

Proof of medical treatment by your medical practitioner underlying the necessity of treatment.

A communication record like any email, call,/ sms between you and the insurance company

The most important documents are EOB and denial letters from the company elaborating the reasons for the denial.

Equipped with all necessary documents empowers your appeal and states your sincerity towards the claim.

Submit An Appeal Regarding The Denial

Appeal is the right of the customer and almost all companies ensure this service to their customer for transparency. This is the main part of the case, so prepare yourself and walk to the appeal counter vigilantly. Claim the health insurance coverage you deserve.

You need to follow the following steps:

1. The first step is the submission of an appeal. For this, you have already prepared your documents, with all of them attaching strong statements and opinions about how the denial is incorrect.
2. Note down the deadlines for filing an appeal against any results of denial. With complete preparation, go to the office and submit within time frames.
3. After submission, don’t sit back ignorantly; you must have a follow-up of your submitted appeal.
4. Check if it has reached the final destination
5. Talk to the employees there about the status of your appeal.

Don’t forget to carefully learn about the insurance company’s policy because every company has its own timeline.

Seek Consultation From A Professional

This process takes place in a defined period, but if it takes too long, you must ask professionals for help. Professionals may charge you some for their services, but their assistance will be valuable in your appeal case. This may include:

• Special  Advocates for insurance
• Skilled person in medical billing
• Legal experts attorneys

Tips For Getting Success In Appeal

Your appeal can be successful if you do it right. Here’s what you need to remember:

• Organise yourself 
• Gather all documents
• Don’t get disheartened by initial setbacks
• Read policies and regulations regularly
• Use technology for better understanding

Conclusion

It’s true that the denial situation is overwhelming, but having proper guidance can leverage your burden.

Knowing the real cause of the denial, policy reviewing, collecting all documents, making a strong appeal and asking help from professional assistance are the parameters for a successful appeal and can turn your chances into your favour.

If you or anyone around you is experiencing the same, you don’t sit back and make a strong appeal case for denial!

References:
https://rehabseekers.com/insurance/in-network/