Getting your Health Insurance Claims Covered

When you submit a health insurance claim, on occasion you may have it denied. Before paying the bill, there are some steps to take to get to it paid. In some cases, there may have been a mistake made by the insurance company and it was supposed to be covered.  Your insurance company may pay the claim to avoid the expenses of handling an appeal. 

One of the most important steps to avoid a claim denial is to understand what is covered and what is not covered under your insurance policy. You may need prior approval from your insurer before the procedure or treatment for it to be covered. If you don’t get prior approval, it may not be covered. All insurance companies and policies are different, so your doctor may not be aware of the required pre approval. 

Some insurance policies require you to use health-related services by certain providers. If you obtain services from out of the network of providers, they may not be covered by your policy. 

If your claim is denied, first review your paperwork file then call your health plan’s customer service line. Sometimes, by talking to the customer service representative, the denial can be cleared up. When you do call, take notes of your call, including the date and time, names of the people you talk to and what was discussed in case you need it in the future. 

If your denial is not cleared up, you may need to start a formal written appeal. Review your insurance policy to determine what paperwork your health plan requires you to file. Information that will likely be needed will be copies of bills, your healthcare provider’s name, address and phone number and your physician’s statement about why your treatment was or will be necessary. If your initial appeal is denied, you will likely have additional appeals available. Many health plans have several steps in the appeal process.   

If your claim is not settled after going through your health plan’s internal appeals process, you may be able to ask your state insurance commissioner’s office to perform an independent review of your dispute.

Some plans offer arbitration, where an independent third party reviews the dispute and recommends an outcome. If arbitration is offered under an employer-provided health plan, federal law says you can’t be charged for using it. 

One of the easiest steps to preventing a health insurance claim denial is being prepared and understanding your policy. If you know what is covered and not covered and follow the correct steps when getting care your claim should be covered by your insurance company.