4 keys to appealing a rejected insurance claim

Published on NewsOK Modified: August 13, 2014 at 9:35 am •  Published: August 13, 2014
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Keep calm and take notes.

Stay true to this principle and you can improve your odds of successfully fighting a health insurer's claim rejection.

Experts who help with the appeals process say patients have a 50 percent chance or better of prevailing. They say a winning argument may require heavy doses of research and persistence, but the end result is a decision that can stave off thousands of dollars in medical bills.

Certainly understanding the limits of your insurance, before you seek care, will help you avoid the frustration of having your claim denied. But if you get to the point where you need to appeal, here are some important points to remember.

1. STARTING AN APPEAL

Learn all you can about why your claim was rejected and don't be afraid to ask questions. If the insurer deems your care to be not medically necessary, request an explanation that includes the insurer's policy language and any information used in making the decision. Keep records of who you spoke with and when.

"Take down notes and get the language down as cleanly as possible," said Stephen Parente, a professor of health finance and insurance at the University of Minnesota.

Maintaining a calm demeanor can help you think rationally, and it may make customer service representatives more inclined to help.

Learn the insurer's appeal process, including any deadlines. A missed deadline can sink an appeal regardless of how strong your case is.

2. BUILDING YOUR CASE

Sometimes a claim is denied due to a clerical error, such as the wrong code being used for a medical procedure. A good starting point is to check with your provider's billing office to make sure your claim was coded correctly. If something is amiss, you can probably get it cleared up with a few phone calls.

Other cases may require an appeal letter. Your letter should lay out the reasons you believe your care should be covered. Ask your doctor to review your argument and offer input.

A physician can help detail how all treatment alternatives were exhausted before you started receiving the care an insurer deemed not medically necessary.

The insurer will want more than your doctor's word, so be prepared to include any confidential medical records that support your case.

Consider including medical journal articles that support your argument or detail the effectiveness of your treatment. These can be especially helpful if your doctor is unable or unwilling to work with you on the appeal. Patients can use the National Institutes of Health website www.pubmed.gov to search journals around the world.

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