How to Handle a Health Insurance Claim Dispute

There are 3 main reasons that a claim is denied so there are 3 answers to – How do you handle a health insurance claim dispute?

The first reason that claim is denied has to do with the person making the claim.
What often happens is that the policyholder does not understand fully how their insurance works. So they may file a claim for a service that is not covered. They may not understand what medical costs go toward satisfying their deductible (not all do.)so they believe it’s been met when it hasn’t. If the patient is under a HMO policy they must use their HMO providers and most services have to be obtained by referral from their Primary Care Physician. It is possible to choose a hospital that is part of the HMO and still have services provided in that hospital by a non-HMO physician.

If the policyholder is the one who has made the error because they didn’t fully understand their policy then they’re pretty much out of luck. The only way to handle this type of claim dispute is to avoid it in the first place. Here are some tips to follow:

Read your policy thoroughly when you receive it. Become familiar with all conditions(do you need a referral etc.), deductibles, co-pays and what services are actually covered by policy.
If you don’t understand what your insurance covers or what conditions apply, contact the insurance company or your human resource person before you use the insurance to clear up any questions.

If you are part of an HMO, make sure all services are performed by someone in that HMO. Don’t rely on your PMP ask the person providing the service. This includes everyone that performs a service for you at a hospital.

The second error can occur in the medical billing office. They could code your claim wrong. Every service provided, medication used, medical supply etc has specific number code (IC9). They use these codes instead of actual words to file claims. If they make an error it could cause a claim to be denied.

You may be able to determine if the claim was denied due to a billing error by carefully looking over the statement or EOB that your insurance company has sent you. Was the service that has been denied actually a service that was performed? If the answer is no, then more than likely it is due to a billing error.

To handle this type of claim dispute, you want to contact the office manager or billing office of the provider in question as soon as possible. Discuss with them the situation. If it was their error all they have to do is correct and refile the claim with your insurance carrier in a timely manner.

The last reason that claim is denied is because an error has been made at the insurance company level. When you receive your EOB(explanation of benefits), and payment has been denied, there should be instructions on the form on how have the claim reviewed. It is important to follow these instructions. Often they wantthe request to be in writing with as much detail as possible. Make sure you document why you believe they have an error and back up with facts. If you have followed the policy conditions, met all of your deductible, sought services that are covered, checked your EOB for billing errors and found none then these become the facts that could win your claim dispute.
How should you handle health insurance claim disputes?:

Always understand your policy. Meet all the conditions necessary to file a claim. Review your EOB’s as soon as you get them. Contact your provider’s billing office or office manager if you find error. Follow your insurance company’s instruction for requesting a claim review.