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What To Do When A Claim Gets Denied

July 10th, 2019 – It’s happened to us all. We go to an lab, urgent care or pharmacy and discover that something we thought was covered isn’t. Of course, the best advise is to do your homework up front and make sure every provider you’re seeing is in-network.

The best way to do this is to carefully look at your insurance ID card to determine the exact specific name of your provider network and then to go to the insurance company’s website to look up providers. While that SOUNDS easy, carrier websites can often be confusing, so it’s often helpful to call the insurance company and then verify with the provider’s billing department that they are in-network for that particular insurance carrier network.

Don’t assume that just because you went to an in-network doctor and because they referred you to a specialist, lab or imaging facility that those providers are in-network. Quite often, doctors will suggest facilities they are familiar with or have a business relationship with. If you think your doctor is going to check to make sure other providers are in-network, you’re setting yourself up for a costly lesson. Be a smart consumer and double check everything yourself.

When the doctor is writing a new prescription, check right then and there to see if the medication is on your insurance plan’s drug formulary, which is a list of what is covered by the plan. Also make note of what drug tier the medication is in and how your plan will or won’t cover that. When the drug costs are high or if the medication prescribed is not on your insurance plan’s drug formulary, it is often a good idea to ask the doctor if there’s a lower priced generic option available that would be equally effective.

If there are no other equally effective alternative medications then you’ll want to ask your doctor to submit an appeal to your insurance company to request an exception. At this point, you have everything to gain and nothing to lose by trying. If it’s medically necessary and there are no equally effective alternative medications, the insurance companies will often approve those requests, but you have to get the doctor involved in the process.

Under the Affordable Care Act (ACA), insurance companies are supposed to cover true emergency (life or limb) treatment as in-network, even if the services were out of network. That being said, it’s not unusual for the first claim to be denied. Fortunately, there is an appeal process that you can follow to try to get the insurance company to pay the claim.

You want to be very organized and methodical in your approach to appealing any denied claims. It’s important to maintain a paper trail throughout the appeals process. If you speak with insurance company representatives, take care to document what department, phone number and extension you called, who you spoke to and what was said. However, be aware that written communications will always carry much more weight than something an insurance companies claims or customer service person told you.

You may wish to call the carrier and request the unredacted notes of the insurance company’s internal discussion about your claim. You might be surprised to learn that the people making preliminary decisions have no formal medical training and may not understand all the nuances of your particular health situation.

Quite often, denials can be the result of the insurance company’s claims department simply not understanding the nature or context of the situation. Claims departments are busy and they are trying to make decisions based upon diagnostic codes, which often paint a very imperfect picture of what’s really going on.

Any formal appeal, should have a plain English summary explanation of “what happened when” to give them an understanding of all the supporting documentation you’ll be providing. You may need to request a letter from your doctor to support your position. Those can carry a lot of weight, if your doctor is willing to help out. You want to provide as much documentation as needed and narrative to help the people reviewing it make sense of it all. You want to make it easy for them to say “Yes.” Your goal is to get the first appeal approved, so you don’t have to go through the even more time intensive second level appeal process.

For most ACA compliant health insurance plans, your deadline for filing the appeal is 180 days after the claim is denied. The insurer must notify you of its decision, in writing or electronically, within 30 days of receiving your request or following the appeal review meeting. It should also provide you with information about requesting an independent external review.

For more details on the appeal process, have a look at the Colorado Division of Insurance’s document, “Your Rights Regarding Pre-Authorization and Appeal Procedures.”

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