A rejected claim is not final; so take a deep breath, relax, sit down and have a cup of coffee. This article may be exactly what you need to help you find solutions for your unpaid medical claim.
Collection of information
Collect all documents related to your medical requirements; for example, an insurance policy, a rejected claim, letters you received from your doctor and insurance company, and much more.
Study and understand the reason for the rejection of the claim.
Read the EOB (Explanation of Benefits) application sent by your insurer because you will see the reason for the refusal. In most cases, the request will be rejected because of the following:
• Errors when submitting application forms, such as a doctor's office, did not use the correct or registered NPI (national provider number), the wrong application form, the wrong service place used for the procedure, the wrong diagnosis code, and more. In such cases, the doctor’s office must file a revised application so that your medical claim is adjusted and paid for.
• Rejected due to existing condition. The insurer will send you a letter requesting a list of healthcare providers that you have seen during a specific period of time so that they can contact your healthcare providers. Request your medical records and the review department will conduct a previous review. If they find out that a diagnosis for a completed medical procedure is indeed one of your pre-existing conditions that fall under the previous waiting period, your claim will receive a final refusal. As a rule, some claims are charged for a previous review within a few months, since the insurer is still waiting for the member to respond to the request letter or medical records.
• Denied due to pre-check. This means that the medical service being performed is a closed service; however, approval must be obtained before it is executed. The institution or doctor must call the after-treatment department of the insurance company before starting the service. Typically, approval services are around the clock inpatient stays, expensive diagnostic services such as MRI and CAT scanning, mental health services, and expensive, long-lasting medical equipment. If, for any reason, no pre-certification was obtained for the procedure or equipment, your health care provider may call the oversight department to get a retroactive pre-certification and re-apply.
• Denied due to lack of predetermination. This is a procedure where a medical provider with a member’s request / approval sent the patient’s medical data to the insurer and recommended medical tests, medical equipment and procedures for non-emergency procedures that are usually very expensive, such as breast reconstruction and bariatric surgery.
• Refused due to timely filing. Requiring timely filing limits varies depending on whether the medical procedure was performed by a non-contractor that indicates that you are located. Usually it is six months from the date of service. It may happen that your medical provider sent a lawsuit before it was filed in a timely manner, a computer malfunction occurred in the insurer's system, and they received only a repeated request. So, do not rush to talk to your provider and know when he first filed a lawsuit. You can ask them to reapply if they can show a copy or proof of timely submission.
• Denied due to participation. This usually happens to newborn babies that are not yet added to the policy. Just call your insurance representative and attach the correction by phone. The newborn is covered by the mother’s policy for the first 30 days of birth for most states.
• Refused because of COB (benefit coordination). If you have another insurer as the primary insurer, your claim must first be submitted to the primary insurer, and a copy of the EOB must be sent to the secondary insurer so that you will be processed.
Contact insurance company
Now that you know and understand why the claim was rejected, pay attention to the information you need, such as your insurance account number, reference numbers of a tentative or predetermined date, the date the claim was filed, medical records and everything related to your claim . Call your insurance client representative (it will take time to get in touch with a live agent, so stay calm). Talk to your insurance representative about your claim; Why do you think this is wrong, and clearly give your supporting information. Request your claim to be reviewed or amended. Always ask for the number of days you must wait before it is allowed, and you can call back to continue. In addition, ask for the call reference number so that when you call back your application you only need to specify your number for the next representative who receives your call and he or she can pull up your accounts and documentation immediately. This will save you time and maintenance will be quick and easy.
Record your conversation with a representative. Get the employee's ID number, as well as the time and date you called. Take notes on the things you talked about during the conversation.
Appeal to the complaints department
If your problem is still not resolved, you can appeal. You can either do this by writing to the grievance department, or send it by fax. There is a timely date for filing appeals, and it all depends on what state you are in. Just ask your broker. You can call your insurance representative and request appeal requirements, a timely limit and address of filing.
