Claim, Claim Go Away
How to Appeal a Denied Claim
Human resource professionals have been reaching out for help for employees facing large, unexpected bills. Some speculate an increase in denied claims is due to the rising cost of care or medical necessity. No matter the reason, it’s important to understand your employees’ appeal rights, should they find themselves in a situation where a claim is being denied after services were rendered, and they’re now responsible for all charges. Insurers must communicate why the claim was denied and how to dispute the decision. Your employee then has six months to submit an appeal.
There are two ways to appeal a health plan decision:
Internal Appeal – This is typically the first and even second attempt appeal. It’s important to ask the insurance company to conduct a full and fair review of its decision.
External Review – Should the first and second level appeal be denied, your employee has the right to a third and final appeal called an external review. The external review means a third party is reviewing everything and the insurance company no longer gets the final say on whether to pay the claim. Typically, the first and second level appeal must be exhausted before an external review.
Prior to writing the appeal, make sure the denial wasn’t due to something simple like an incorrect policy number or misspelled name. When writing an appeal, it’s a good idea to get help from your insurance broker. Since you only have three attempts, it’s best to ensure the request includes all pertinent information.
Things to include in an appeal:
1. Detailed letter explaining the issue and why the claim should be paid
2. Supporting documentation from the doctor’s office:
- Medical notes
- Medical history
- Letter from provider with expert opinion on why the treatment was necessary
3. Any additional information supporting the case that might not have been included
After all is submitted, be patient for the response. Most insurance carriers must notify your employee within 60 days of receipt, however, it can take less than 30 days. Set a calendar reminder to check the status, so it’s not forgotten. It’s also a good idea for your employee to reach out to the provider who’s billing to let them know the denial is being appealed. The provider can put a notice on the account, so your employee isn’t sent to collections. If in the end the appeal attempt isn’t successful, it’s recommended your employee talks to the provider to try to negotiate on what’s owed. Often providers will reduce their charges, especially when involved in the appeal attempt. The worst they can say is ‘no’ so it’s worth asking!
For a deeper dive into the appeal process, contact a member of the ‘A’ Team today.
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