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Goliath struggle, but the battle is worth waging if you've got a legitimate case -- and winning is easier than you might think.
Health insurance companies in most cases aren't out to cheat you. Many wrongful claim denials stem from coding errors, missing information, oversights or misunderstandings.
Here are six steps for winning an appeal: Find out why the health insurance claim was denied The insurance company should send you an explanation of benefits form that states how much the insurer paid or why it denied the claim.
Call the insurer if you don't understand the explanation, says Katalin Goencz, director of MedBillsAssist, a claims assistance company in Stamford, Conn. If it's a simple error, the insurer might offer to straighten it out. But double check to make sure your insurer follows through, Goencz says.
Read your health insurance policy Understand exactly what is covered under your policy and how co-pays are handled.
Health insurance plans differ. Usually the health insurer includes a summary of benefits online, but you should read the policy itself, says Rebecca Stephenson, president and CEO of VersaClaim, a claims assistance and patient advocacy business in Austin, Texas.
Ask the employee benefits department or your broker for a copy. Learn the deadlines for appealing your health insurance claim denial Read your health plan and learn the rules for filing an appeal.
If it's a complex case and you're concerned about meeting the deadline, send a letter stating you're appealing the denial and will send further information later, Stephenson says. Make your case Gather documentation to back up your argument.
Sometimes the problem stems from something as simple as a billing mistake by a doctor's office. Stephenson tells of one client whose health insurance company denied a claim for surgery because her deviated septum was named as the diagnosis. The insurer did not cover surgeries for a deviated septum.
But she was also diagnosed with acute purulent sinusitis -- the real reason for the surgery, which was never communicated to the insurance company. Stephenson had the client submit copies of her medical reports, X-rays and a letter from the physician confirming the sinusitis diagnosis.
Write a concise appeal letter When you write an appeal letter, be sure to include your address, name, insurance identification number, date of birth for the person whose claim was denied, date the services were provided and the health insurance claim number, Goencz says.
Send by certified mail to get notification that the packet was received, she adds. If you lose, try again "If you lost your first appeal, you've got to step back and look at why the health insurer is saying no," Stephenson says. If you exhaust the appeal process and are still unsatisfied, you can take the case to the state department of insurance, unless your coverage is through an employer that is self-insured.
In that case, your next stop is the U. Department of Labor, although both Goencz and Stephenson say getting federal officials to act is a long shot. Hire a professional patient advocate or claims assistant.
You can get names of claims assistance professionals in your area through the Alliance of Claims Assistance Professionals. Related Articles on Insurance.Once you have determined that you must appeal a car insurance company decision, you should outline your case in a letter to the insurance provider.
The information should include the facts behind the accident or claim, the reasons you are appealing the car insurance company decision, and all supporting documentation. Have you used one of these Sample Letters? Was it helpful? We would really appreciate your feedback.
Take our 2 minute survey. The Financial Rights Legal Centre provides several letter templates that you can use to write to your creditors, insurers or Ombudsmen. For example, if you sent your insurance company a letter advising them of a change in your circumstances (this is your responsibility), try to find a copy of the letter.
Contact the insurance company Once you’ve taken a look at your policy, it’s time to get in touch with the insurance company. Advanced Insurance Management was able to negate the premium that the insurance company was trying to apply.
I would highly recommend Advanced Insurance Management to anyone that is involved in a dispute with their Workmans Compensation Insurance carrier. This is the proper way to dispute a workers’ compensation audit when an additional premium is due.
Ross Driscoll Sr., CIC, CR, is president of National E&S Insurance Brokers. He is a licensed fire and casualty insurance agent and broker, surplus lines broker, reinsurance intermediary broker, and . For your use, we provide you with an insurance sample cancellation letter below.
If you want to cancel your current policy, you should send an insurance cancellation letter or termination letter to notify the insurer to cancel the policy or request to refund the remaining portion of the premium.