When you need a medical claim, you don’t want to be concerned about whether or not your insurance covers it. Unfortunately, there are many reasons why a medical claim can be denied. But there are steps you can take towards reversing the claim denial. If you follow these tips, you’ll have the highest chances of your next denial appeal being a successful one.
Know Why the Claim was Denied
Before you start your denial appeal, you have to know what caused your medical claim to get denied in the first place. Your explanation of benefits (EOB) can provide you with an explanation by using codes. Most EOBs will even give you a key to these codes, so you can determine what they mean if you are unsure. If you’re still unsure after that, you can contact the Payer that denied you and ask them yourself. It is your right to have this information, so get whatever information you need to find out the source of the problem.
Eliminate Easy Problems First
Sometimes, the problem can be resolved easily. It may just be a misspelled name or a data-entry error that can be fixed with ease. Look for errors in your documentation. If you find any, get the insurance company to fix them before you move on. If the medical provider made the error, ask them to correct the issue and then resubmit the claim.
Gather your Evidence
Before your denial appeal, get all of the evidence you need to show that the services you’re asking to have covered are medically vital. Your denial appeal is more likely to be successful if you have evidence such as prescriptions from doctors or referrals, as well as all relevant medical history information.
You’re also going to want to reference your health plan’s medical guideline for whatever treatment you got. You can usually find these online using your health plan’s website.
Submit the Right Paperwork
To get a successful denial appeal, you might have to write a letter to the insurance company. If you do write a letter, put your claim number in it, as well as the number on your health insurance card. However, your claim could get processed more quickly if you use your insurance company’s standard appeals form. You should be able to figure out how to appeal the decision by reading the EOB you received or contact the insurance company directly to find out how you can appeal.
Pay Attention to the Timeline
You have to follow up with your insurance company after you’ve called them the first time. Put a system in place that will remind you to follow up with them. If a customer service agent informs you that the will resubmit your claim and that it could take roughly a week to get processed, make a note to contact them after a week and see how everything is going with the claim. A denial appeal is more likely to be successful if you gently nudge the insurance company every now and then.
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