On denial, one should critically read the denial notice and try to understand the cause of the refusal. The details about reasons explaining why the claim was not approved should be included, with all the policy terms or conditions that are cited. With this information, one should contact the customer service or claims department of health insurance for a discussion. You’ll want to gather all your backup documentation: your medical records, bills, and any correspondence that has occurred thus far.
Verify within your health insurance policy that the claim is a covered plan benefit because many times a coverage has been denied based upon an oversight or an error, sometimes in the coding or in the information. If you feel that the denial was incorrect or that there were extenuating circumstances under which your claim should be covered, you always have the right to appeal it with your insurance company. Most often, this process will take the form of a formal written request for reconsideration with supporting documents, along with detailed explanations soliciting why the claim should be paid.
Throughout this process, keep good documentation of all the correspondence with your health insurance plan, including the dates and the details of the name of the representative, and the substance or nature of the conversation. Should your appeal be denied, or if you get stuck at any one point, you can contact the insurance commissioner of your state or a consumer advocacy group for an advisor who can walk you through the process. If in any case the dispute cannot be resolved in any way, it has to be pursued in court or even take the route of alternative dispute resolution to set it straight. In following these steps in a timely and organized way, you will increase your chances of successfully overturning a denied claim.
