Tips on Appealing Denied Health Insurance Claims

Claims insurance companies have many processes in place to ensure their money, or their client's money, is protected. Whether you are the subscriber of a Third Party Administrator (TPA - a plan administered according to your employer's specifications) or a Health Maintenance Organization (HMO - a plan administered according to the health insurance company's specifications), you have resources that are available to you in the event that a medical claim is denied. This article will outline some of those resources, and tips for ensuring you are not paying for services that the insurance company is responsible for.

1. With every claim submitted to your insurance company by your doctor or hospital (the provider of service) you should receive an Explanation of Benefits (referred to as the EOB). Whenever the insurance company submits and EOB to you, a copy is sent to your provider of service. Save each and every EOB, even if it is only stating that nothing is being paid because it is a duplicate claim. Each EOB corresponds to a claim number in your health insurance company's system. When contacting them, it will be most beneficial to be able to reference the EOB or claim that the customer service representative is referring to.

2. When contacting customer service always write down the customer service representative's name, the date and time you're calling, and any specific details of your conversation. It is standard practice for Customer Service Representatives (CSR) to take notes of every call they have taken throughout their shift. If you have your own record of your call that is more detailed, it is likely that your call will be taken more seriously by another CSR or, if necessary, their Supervisor. This detailed account will also be very useful should it become necessary for you to write an appeal to the insurance company.

3. Many times when contacting Customer Service it will be necessary for the CSR to escalate your problem to a Claims Adjudicator; they normally do not handle the adjusting or even review of your claim themselves. CSR's are also accustomed to taking incoming calls, and won't normally contact you with updated information, claims resolution, or further explanation of your claim denial. For this reason it is always a good practice to request from the CSR their expected turn-around time on claims reviews; in other words, how long is it going to take before you can make a follow-up call for more information regarding your claim. Though turn-around times vary, it is a good habit to give the Claims Adjudicator one week to review your claim and make any added notes to your account before making a follow-up call.

4. If during your follow-up call you discover that nothing at all has been done with your claim, immediately request a Supervisor. This is where some of that information you wrote down on your first call will come in handy. Even though the first CSR may not necessarily be the one reviewing or making changes to your claim, they are the one responsible for following-up to make sure the Claims Adjuster did review the claim. Having that CSR's name will ensure that someone is held responsible for your claims service, and also lend credence to your insistence that you receive a more immediate action on your review. Remember that even when you're speaking with a Supervisor it is critical to get their name, a direct number for further contact, or the name and number for a direct contact of the Supervisor's choosing. Another follow-up will be necessary using that direct contact.

In most cases, these steps will get you satisfaction with your claims issues. However, if your claim is still being denied and you are not convinced it should be, an appeal process will need to be followed. Most companies have specific appeal guidelines that are necessary to follow in this case. Your direct contact -whether it is the Supervisor you last spoke to or another CSR or Senior CSR- should be able to explain the written appeals process to you.

1. The person you speak with last will most likely not explain the written appeals process to you unless you specifically ask for it. The process is usually found in writing on the back of your EOB. It's best to verify the information from the back of the EOB with your direct contact. Sometimes that person will generously share with you additional information not listed on the EOB if you request it.

2. Involve the provider's billing clerk as soon as you know a written appeal will be necessary. In most cases they will hold your account as long as they can instead of sending it to collections. In some cases your provider's billing office will be more than happy to assist you with writing the appeal, if they haven't already tried writing one of their own. In these cases, the provider's billing clerk is a tremendous resource: they are more than willing to help as much as they are able, because the sooner the issue is resolved the sooner they will get paid as well.

3. During the writing of your appeal make sure you have any and all documentation from your provider to send with your appeal. Although this is very particular to the denial reason, in many cases something in writing from the provider is necessary for documentation. Example: most insurance plans cover only one routine PAP exam a year for women over the age of 18 years old. If a female patient has had her exam earlier in the year, but is now presenting at the office with pain in her ovaries, she will have another PAP exam that is non-routine. If coded incorrectly, the non-routine exam will be denied. If the provider re-submits using a corrected diagnosis, making the claim non-routine and subject to consideration under the medical benefits instead of the already exhausted routine benefits, but the insurance company wrongfully denies it as a duplicate of the first claim instead of reconsidering it as a corrected claim, it will be necessary to submit an explanation and documentation from the provider's office proving that the claim was a corrected claim, and not a duplicate.

These procedures should assist with the correction and payment of many claims issues that occur in health insurance claims processing. However, if you feel you have been discriminated against for benefits for any reason, or if you feel the claim issue has not been resolved to your satisfaction and you have exhausted your written appeal, it may be necessary for you to involve your local Office of Insurance. Each state has an Office of Insurance that regulates licensing and regulations. The following link will assist you in finding the Office of Insurance for your state:

Offices of Insurance
The most important step to remember in health insurance claims appeals is documentation, documentation, documentation! Whether contacting the company in writing, via email, or on the phone, keep all documentation and always get the name of who you are speaking with.

Remember, most insurance issues can be resolved by knowing your benefit plan. When changes are made and you receive new information from your employer, be sure to review the benefit changes and know what your costs will be and what will be covered before going to the provider. Even if the insurance company itself stays the same, changes are usually made in benefit levels, co-pays, and what diagnosis will be covered. Before having any major procedures done contact your insurance company's Customer Service Department and make sure the procedure will be covered, whether or not you will need an authorization, and how much of the expense will be yours vs. how much will be theirs.

Oh, and be sure to get the Customer Service Representative's name, even when verifying your benefit levels.