Q: How can I make sure that my claim won’t be denied?

Denied claims have become major problems for quite some time now. However, just because your claim got denied that does not mean that there is nothing that you can do about it. However, you can in fact, miss your chance and let the denied claim continue to be ignored. Make sure that your company provides you with this information when they send you your denied claim:

• A statement for specific scientific or medical reason for denial
• A description of alternative supplies, services or treatment that are covered, if any
• If the denial is upheld in the internal review, instructions for filing an external request for review should be provided
• Instructions for initiating internal appeals of denial
• A statement identifying the provision that excludes the treatment
• The title, medical license number, name and state of licensing of the person making the denial decision

If you didn’t have a piece of this information, feel free to contact your insurer and ask for it. They are obligated to provide you with this information for a proper analysis that will tell you why your claim was denied.

If you believe that your claim was denied unjustly, make sure that you make an appeal. Even though it might take some time, they should send you a response to your appeal and the chances of you getting an approved appeal are higher than you think.

Here are the state and federal mandates that affect your appeals process:

• Executive agencies must implement grievance and appeal procedures recommended by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry.
• Grievance and appeal procedures must be followed by managed care plans that contract with Medicare as part of their contract
• In order to help consumers with their appeals, several states sponsor patient-assistant groups
• There are some laws in states that let physicians appeal a claim on behalf of their patient