Do you need an appeal in case your health insurance claim is denied?

There are people who are taken by surprise when one of their health insurance claims is denied. Health plans might be denied pre-authorization requests because of missing data. In order to prevent this, you should ensure your pre-authorization requests so they will include accurate patient information. You might also want to check with your doctor’s diagnosis and procedure codes for accuracy.

By providing a good documentation, you will avoid denials and make sure you write the name of every person you talk to in reference to your health insurance problems and keep backups of all correspondence and paperwork. In case your insurer denies your claim, the documentation will turn to be invaluable.

Patients need to read the handbooks provided by their health plans. If you plan any treatment, make sure it is covered under your insurance before treatment is received.

There is always a face-to-face appeal in case your health insurance claim is denied. A person is allowed to attend at least one appeal hearing. Since most plans allow or deny treatment based on whether you need medical intervention for your well-being or not, make sure that you ask your doctor to contact the plan’s decision maker.

An appeal is necessary because your chances for success may be better than you think because there are 42% of doctors who say that their most treatment denials were ultimately resolved in the patient’s favor. Make sure you follow a clear appeal process. You can appeal within the time limit - 60 days. First you can try to complain by phone, and then move to the appeal itself.

There are two methods of this appeal: internal and external. The internal appeal is to the insurer itself; an external appeal is to your state department of insurance.

The internal appeal is the first step of the appeal process where you can ask for more information in order to reconsider its decision. External appeals are filed only when the insurer won’t reconsider your case. If you win your appeal, your insurance company has no choice, but to submit your claim.

If your plan is self-insured, it is not subject to state laws; if your plan isn’t self-insured, make sure you contact the department of insurance in your state to determine what laws apply. During an appeal process, you should find the right person to whom you should send your appeal letter to. Make sure you send all letters by certified mail and keep a record of having the sent letter and a receipt that it was received.

A health care professional with appropriate expertise is required to participate in the appeal process.

Laws in some states specify a role for doctors, recognizing that they may appeal a claim on behalf of a patient. Many states protect a physician’s right to advocate for medically appropriate care by prohibiting plans from punishing doctors who do so. Some states sponsor patient-assistant groups to help consumers with their appeals.