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What you need to know before buying Health Insurance  

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Claim Denials: How to Appeal Non-Payment of Your Medical Bills

First rule of thumb is to be familiar with your rights and the provisions of your policy! The policy is the contract that an insurance carrier has with its members regarding the terms of their health coverage including, limitations and exclusions, and payment of claims. If you feel the terms of the contract are not being met, do not accept the denial and move forward in seeking a resolution with the carrier. Call your health insurance company, address your concerns and request evidence to support their decision to deny health coverage or payment of claim Ask for specific reasons why your medical procedure or treatment was determined to be unnecessary, not covered or payment denied. Once you know why the claims processor refused your claim, ask what paperwork or information is necessary to reverse the denial. More than likely, the insurance carrier will ask you to submit in writing a letter of appeal requesting reconsideration of denial of the claim.

If the insurance company requires you to submit a letter of appeal within a specified period of time, call your doctor's office immediately and speak with him directly. Spell out the documentation you need and why the insurance company requests it. Ask your doctor to include the following information:

• A thorough explanation of your condition or disease
• An accurate description of the treatments available
• The reason why it is medically necessary

Be courteous, persistent and patient when appealing claim denials. Get in the habit of faxing or emailing your appeal letter to whomever you speak and be sure to send the original by certified mailing with return receipt requested. If you have not been able to resolve the issue with the insurance carrier through their claim appeals process; then, consider seeking guidance from your insurance broker or assistance through your state's department of insurance consumer affair unit.

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