How To Fight A Denied Medical Claim~

TroubleShooter May 22, 2010 Health
Most Denied Claims Are Due To Human Error.

1. Call your Insurance Company to find out why claim has been denied, get names of everyone you have contact with.     

2. Ask that denial be explained to you in detail, you have the right to know and to have it explained, no matter how many times you ask.

3. Contact provider of the denied service, ie: Dr's office, hospital, request your record of said date of service.

4. Understand your Ins coverage, you should know your policy better than anyone else. 

5. Research common medical terminology online.

6. If denial is due to error in how it was submitted by provider, make sure it's corrected and keep calling provider to follow up. Squeaky wheel gets the grease.

7. If error is due to a non-covered service in your policy, these are more difficult to fight, although with almost every denial, you have the right to appeal it.  This is why you should understand your policy coverage. 

8. All appeals you submit to your Insurance Carrier need to be in writing, save copies of everything you submit.  Get names, extensions of everyone you come in contact with. Most appeals processes have different levels. Make sure you follow all levels correctly, you don't want to start over at level one when you thought you were on level three.

9. Most claims are denied due to: Incorrect diagnoses code, Incorrect procedure code, Missing information, Deductable, Non-covered services.

10. Providers of medical services are likely to have a contract with your Insurance Company, which means they have certain procedures they must follow.  They may not bill you for a service which has been denied due to an error on their part.  They may bill you for a non-covered service.

11. Providers of services are responsible for obtaining all prior authorizations prior to you receiving such services.  They may not bill you if this criteria was not met prior to providing you with said services.  You may be billed if such authorization is not a guarantee of payment, you may be required to sign a waiver stating you understand this action.

12. Always call your Insurance Company prior to you receiving a complicated or expensive test, exam, x-ray, etc, for guidelines of coverage, be your own guardian of you healthcare.

13. If claim has been denied not due to billing error or non-covered service, it may have been denied just because of human error at the data entry level at your Insurance Company.  Most claims submitted by providers are done so at an electronic level and very few mistakes are made. However, those who submit on a paper claims will have a higher risk of denial. 

14. If the denial is due to an error at the Insurance Company, they must rectify this error and reprocess the claim, without having the claim be resubmitted by your provider.  Once it has entered their system, it's there.

15. Most important, keep a record of everything you do in the process of fighting a denied claim.  Be educated in your healthcare, and be aggressive in your pursuit.  Most denied claims are not fought, and are paid out of pocket by a patient. It is expected for you to not know what you are talking about or understand the process,,, surprise them by being aware and informed.

16.  You have the options of filing complaints with either your states Insurance Commisioner and or your states Attorney General's office if you feel that you have not been treated fairly by your Insurance Company or representiative of the company. You can find this information via the web.     Be persistent!


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sandra mangum on Sep 23, 2011
ok i did all of that but they still denied me and i have a bone dease and i need to be back on my meds for it .. im not sure how to do it anymore because i got denied from ssi and willfare if u can write back to me my email is thanks