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Being Heard: Denied Health Insurance Claims

As promised from last week's post, we are going to briefly discuss the appeal process if you had a claim rejected by your health insurance provider for whatever reason. Generally, you can appeal any denied claim you want to. Just be aware that, since the medical insurance companies are likely to have the government on your side, your chances of success will be slim. Nevertheless, if you feel you have been done an injustice, you should definitely apply and see what happens.

Similar to an internal grievance process at a company for civil rights violations, etc., you will have to start off by doing an internal appeal with the company. You will have to fill out a bunch of basic information when applying for an appeal, such as your name, address, date of birth, and your policy ID number (found on your insurance card). Your insurance card should also give you a customer service phone number that you will need to call to get started. This is where the fun begins. It is highly recommended when you start making your phone call, to have the bill in question ready, so that you are prepared to discuss whenever you get a hold of someone.

It is also recommended that you're prepared to take notes, including the Five W's we've mentioned in earlier blog posts:

  1. Who did you manage to reach? This is important, because if you have to call back, you know a specific point-of-contact you can refer back to.

  2. What was the result of the discussion? Include negative outcomes.

  3. When did you call (include date and time, especially if you have to call back multiple times in a single day)

  4. Where did you call them (a phone number and extension is usually sufficient for these purposes).

  5. Why did you call them? Is this regarding a denied claim? Denied healthcare provider? Surprise billing?

Write all of this down, either in a physical notebook, or in a phone log. This will help later when you're appealing your denied claim in the future.

Make sure to mention that you would like to appeal your insurance providers decision to deny your claim. The customer service representative should provide you with instructions on how to submit an appeal, including any websites you have to visit, forms you have to fill out, download and mail, etc.

The form will require all of the information as discussed in the second paragraph, however, in addition, you will also need to provide a brief written statement, why you disagree with your health insurance provider's decision. Keep in mind that based on yesterday's post, there are three valid reasons for arguing against your insurance providers decision. To summarize they are as follows:

  1. Your plan does not meet the minimum essential coverage requirements.

  2. Your plan is not affordable.

  3. Your plan does not have minimum value.

Write all of this down, either in a physical notebook, or in a phone log. This will help later when you're appealing your denied claim in the future. requirements, however, you never know for sure unless you make the appeal. The written statement is also an opportunity to appeal to the company as a human being. Explain how the insufficient coverage is giving you undue hardship --- how does it affect you and your family? Are you paying excessive premiums that are making it hard to survive, pay rent, etc.? This is the opportunity to say these things.

After you write and submit your written statement you will likely have to submit it, either through submission of an online form, or through the mail. If you're sending any correspondence through the mail, make sure you get a tracking number with the post office, so you can ensure your form was delivered and postmarked in a timely manner. Then, you will typically have to wait, usually anywhere from 4 weeks to 2 months, so be prepared for this. Also be prepared to get rejected on the first attempt.

In the case that your first appeal is rejected, you will have the opportunity to submit a second-level appeal, which will typically go to your medical insurance's headquarters. This process will be virtually the exact same as a first level appeal, except you will be sending the form to a different address. The appeal process will also take longer than the first level appeal (typically around 2 months), so be prepared for even more waiting. In the event that your second level appeal is also denied, you may be done with your insurance company, but there are still options!

The next recommended level of action is to do an external appeal. You will need all the correspondence you obtained from the first and second level appeal (including those phone logs that you've been taking), and you will have to submit an updated written statement, that reflects why you still don't agree with the decision of the internal appeal process. You will submit this request for an external review to the National Association of Insurance Commissioners (NAICs), which will have different offices depending on which region of the US you reside in. Here is a link to their website. You will want to contact them in the same way you've contacted your insurance company during the internal appeal process, either through e-mail or phone conversation. Expect another 2-4 weeks of waiting before a decision is reached. Hopefully, at this point, you will get some good news, but at the very least, you will have made the government aware of another unhappy health insurance customer, which may eventually allow healthcare reform to take place. After that, there's not much else you can do, unfortunately.

If you have any additional questions about health insurance, you can get them answered by visiting the Employee Benefits Security Administration's (EBSA's) website, or by giving them a call at 1-866-444-3272. They are more than happy to assist with any additional questions you may have, and are very knowledgeable. I definitely recommend them!

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