Is following the rules really enough to avoiding claim denials?

It is obvious that you comprehend that if you don’t follow the rules f your health plans, your claims will not be covered. Sometimes your claim is denied even after you do everything right.Following the rules is also very important if you want your claim to bring satisfactory results. However, sometimes it simply isn’t enough.

Negotiating with your own health care contract isn’t your responsibility when you have a group health plan through work.  Nevertheless, you should ask your employer plenty of questions about your group health plan in order to fully educate yourself. By following these five steps, you will avoid “claims surprises”:

If you have any problems with a claim, don’t hesitate to call the insurer and ask for an explanation. Remember to take detailed notes during the explanation. This step is crucial to follow. As a matter of fact, many claim denials are caused by misunderstandings between the consumer and the insurance company itself.
 
If you still didn’t understand all of the necessary components in your claim, or if you simply think that meeting someone face-to-face would be more effective, visit the person in your company responsible for benefits administration. Their position and great knowledge of the health plan details will assist you further to quickly resolve your problem.

Be absolutely sure about your benefits or providers covered under your plan – never rely on what you think is true. Make sure that you double-check whether the services, providers and benefits you need are covered under you plan.

You should do this before you receive treatment. This can be done by calling your plan’s customer-service department. Don’t forget to take notes. Write down the representative’s name, the date and the time, and the general details of your conversation.

If you find out that your benefits or providers have changed, and you have not been informed, bring this to the attention of the person in your company who is responsible for benefits administration. Ask if this situation is covered under the company’s contract with your health plan.
 
File a grievance with your health plan if your claim is unresolved. Don’t give up if you get a denial. There’s always a good chance the denial might be reversed. The complaint eventually goes before a state sponsored grievance committee that’s outside the plan. This is true in many states. “If a health insurer or health maintenance organization refuses to pay for a treatment it considers medically unnecessary or inappropriate, you may be able to have an Independent Review Organization review the decision,” says Texas Insurance Commissioner Jose Montemayor.