MORE ABOUT DENIALS

Sometimes getting a claim paid is like trying to get a promised mail-in rebate. That is, if you had to pay yourself for all the work you had to do to get it, you’d be in negative territory.
The most common reason for denial is: any guesses? It is an incomplete claim.

The insurance company needs what is called a “clean claim.” A clean claim has all the required information on it, your identifying information (like name, address, date of birth, policy number), provider identification (dr. name, address, etc.), the date of service, and information about the service itself (office visit, code, diagnosis code or description). That sounds like a lot, doesn’t it? Not really. All that fits on a standard one-page form called a HCFA (for doctor, clinic, and medical equipment claims), or on a UB-92 (for hospital claims).

Do not give up automatically upon receipt of a denial letter. Often a claim will be resolved without your doing a thing, because a duplicate letter has gone to the provider. The deficiency letter is more likely than not, perfectly intelligible to the billing department, and the followup claim with the requested material is quickly sent by return mail or fax to the insurer. However, the handling of the reply is not handled with the same urgency as the initial claim. If the insurer requests medical records, x-rays, a pathologist report, etc., the process will stretch over a month.

So before launching a full-scale attack on the insurer, please call the provider’s billing department and check if they have received the same letter and what their response will be. If they are already handling it, or if they treat it as a routine matter, you can resume your normal life. If on the other hand they do not deal with insurers, or do not waste energy on appeals, etc., then you will have to go into high gear.

Typically ninety percent of consumers drop their appeals before exhausting their options. According to a study by the Kaiser Family Foundation, 52% of patients won their first appeal for each claim made. If your first appeal gets turned down, make a second appeal because second appeals won 44% of the time. And third appeals won in 45% of cases. There is no reason to give up if you truly believe that your policy covers a given procedure. Follow the instructions for an appeal. An informal appeal is fine for routine services.

First, pull out your denial form or letter and look up what the denial code is and what it denotes. Then pull out your copy of the policy and go through its provisions with a fine toothed comb. It is true that some of the finer points are not given in the copy that you own, such as definitions of terms, or which doctors are in the network, etc. But the insurance laws are such that the policy you have been given, with the application and any riders, constitutes the whole contract between the insurer and you -- (see section on Your Rights As An Insurance Consumer) -- and they cannot add new material wholesale after the fact of granting you coverage. (Language in the contract will refer to providers in the network, and even though the providers are not listed in the contract, this is a valid part of the contract by virtue of being referred to in the section on how payments are calculated.)

So now you have read through your policy and you still feel that your procedure should be covered. Gather together your denial, explanation of benefits, your appt. calendar, any notes you kept on doctor visits and doctor recommendations. This is especially true for emergency visits to the E.R., when they will want to know if you called your doctor’s office and did he/she send you to the emergency room.

Call the insurance company’s customer service line, or go to their website, and make an inquiry as to the exact reason for the denial or why payment is delayed. It may be that the definition of a term is not the same as in ordinary English usage; many definitions are specific to insurance. You should be able to check this information on the insurer’s website, or look up material on the FAQ page of the website. Try asking the customer service rep what the reason is for the denial, and do so politely. The rep may not have that information available yet, as your claim may be stuck in processing. Get a name of a department supervisor and his/her phone number to call next. Then call that person to ask him/her to check into your problem and ask for a followup letter.
The next step is to go online to the NAIC website. This is the National Association of Insurance Commissioners. On the website you can click on a button to contact your state commission. Then you will be able to access a great deal of information about health insurance in general, and about how to proceed in your case. (Your state office will often have email or instant response to your complaint.) Your HMO may also have an appeal task force; ask about the correct procedure to appeal your denial.

Make note of any deadlines for receiving an appeal. If one is given and you are mailing a reply within a week of that deadline, send it certified mail to prove that you met the deadline. Never send originals of insurer paperwork (but keep copies for your file).