Health insurance has been a hotly debated topic in the recent past, and the enactment of the Affordable Care Act in 2010 was considered a landmark reform regarding the laws governing health care provisions. The Act ensures all health plans adhere to a minimum set of standards including the establishment of an internal appeal process, and provides provisions for an external appeal process in the event of unresolved health insurance claim denials. Thus, knowing the process in which you can fight a health insurance denial will increase your chance of winning your rights without having to bow down to the pressures exerted by the insurance companies.
You have the right to know why your claim was denied
As the first step, you should know that you have the right to know why your claim or the coverage has been denied or terminated in the first place. The insurance company also has to notify you how you can dispute the decision to deny the claim or end the coverage. In general, you should be notified of any denials within 15 days of prior authorization, and within 30 days of medical services already received or within 72 hours for urgent medical care cases. At the same time, if you request it, your insurer should also provide you with the information regarding the experts consulted during the claim processing. According to law, you should also receive information pertaining to the local consumer assistance program with the denial notice itself.
You have the right to appeal
Once you receive a denial notice, you have the right to apply to your insurance company. You have to make such an appeal in writing within 6 months of receiving the denial notice. The process is called an ‘internal appeal’ and you must adhere with the process laid down by your insurer for such situations. You can also submit additional documentation to strengthen your claim during this process. You have to remember that in most instances, before you can lodge an external appeal, you need to undergo an internal appeal process. Such internal appeals can settle in the favor of the appealing party if all the documentations are in order.
You can re-appeal even if the ‘internal appeal’ is unsuccessful
If the internal appeal ends without a favorable response, you can opt for an independent review. An expert whom is not directly employed by the insurance company undertakes the external appeal. Therefore, patients and the doctors will have more say on the matter and the insurance company will not be the final decision making authority. However, you will only have 60 days to apply for an independent review. In certain instances, if your case is urgent, you may be able to file for external review at the same time as filing for an internal review.
Thus, a denial of payment for a health insurance claim is no longer an end to the process but you as the consumer have enough options to win your rights if the claims are legitimate.