Have you ever found yourself in a situation where your health insurance refuses to cover a certain medical bill that you thought would be covered? Bills such as visits to a provider who was once in your network, and without notice was removed from the network is a prime example. Sometimes mistakes are made, and just because your insurance carrier denies your claim, doesn’t always mean that you will be left to foot the bill. There are steps that you can use to take action and try to ensure that you will receive the coverage that you have been paying for. By filing an appeal or disputing a health insurance claim, you can hopefully change the outcome.

Internal Appeal vs. External Appeal

There are different types of appeals processes. You can use an internal appeal where your insurance company will review the case and make the decision. If the internal appeal process does not work you can use an external appeal where an independent third party will review and then have the power to make the decision, meaning the insurance company will not have the final say.

Ask for Help!

We are here to help you! Being insurance brokers, we work for you, not the insurance company. We protect you best interest and help you in any way we can. Many times, we have the relationships built, know the loopholes, and have past cases that are similar that we can use to help get a favorable response.

Don’t Take No for an Answer

Sometimes, the insurance company’s representative on the phone is simply following their basic protocol. The agent may not have the authority to make decisions beyond there guidelines, so ask for their supervisor. If the supervisor doesn’t give you a positive answer, ask for the department that can escalate your case for review.

Reach Out to Contacts

We reach out to contacts at your insurance carrier. Sometimes, relationships can help you get the answer you want to hear or point you in the right direction. Also, our relationships with people at the insurance company may benefit you in the form of exceptions for your case. Some of our contacts have that authority. Remember, sometimes it’s who you know! If that’s not enough, we ask about filing an appeal. Identifying similar cases may help in finding a loop hole or scenario that you can benefit from. This can determine the likelihood of getting an approved appeal.

Be Patient

Disputing a health insurance claim is a lengthy process. It can take up to 90 days to conduct the appeal, so patience is a virtue.

Prevention

The best way to avoid disputing a claim is to read your policy and the updates that are sent to you. Do your research and learn exactly what you have coverage for, who is in your network, etc. If your doctor recommends a procedure, you will be better prepared to ask questions.

Sometimes there are things in your plan that you don’t understand, or words that you have never heard before. If you any questions about your plan, contact us at 954-828-1819 or visit us online at mhginsurance.com.