Fred’s son, Jimmy, exhibited behavioral challenges from a young age. As a teenager, Jimmy exhibited less control. Jimmy’s treating psychiatrist concluded that intensive out-patient therapy wasn’t working and Jimmy needed in-patient treatment. Jimmy’s psychiatrist determined the best treatment facility was located in the Western US, far from Jimmy’s home in an Eastern state. Fred’s health care insurer, part of the Blue Cross Blue Shield, was non-committal about pre-approval. The psychiatric facility agreed to accept Jimmy as a patient, because most Blue Cross system members covered the costs of care which ran $18,000 per month. After 6 months of in-patient treatment, Jimmy was discharged as his condition had markedly improved. The health insurer refused to pay the claim. Fred now faced paying a health care bill in excess of $100,000.
Still “No” – Request an External Review *
If your claim is still rejected after your internal appeal, you can file for an “external review,” in which an independent third party will go over your case. Many states have external review procedures but not all. If your state doesn’t have an external review process that meets the minimum consumer protection standards, the federal government’s Department of Health and Human Services (HHS) will oversee an external review process for health insurance companies in your state.
* As of March 2016
District of Columbia
HHS Administered Process/Independent Review Organization Process
Northern Mariana Islands
Usually the outside reviewers are health professionals who have experience managing medical issues in the nature of coverage sought. The quality varies by state. External reviewers consider
- Any denial that involves medical judgment where you or your provider may disagree with the health insurance plan
- Any denial that involves a determination that a treatment is experimental or investigational
- Cancellation of coverage based on your insurer’s claim that you gave false or incomplete information when you applied for coverage
6 Tips for Winning Your Health Care Claim Denial Appeal
Many people give up too easily. Although a tedious process, we have found that if done correctly there is a good chance that you could win your appeal.
1. Learn why your claim was denied
You need to understand why your claim was denied before you can fight. Start with reviewing your explanation of benefits (EOB) and the codes used to explain the decision. The EOB is a standard form sent by the insurance company whenever you have a claim, regardless if it is approved or denied. Research the codes on your EOB and learn what they mean and if they are correct.
2. Investigate Errors
Sometimes a payment was denied due to a simple error. Check:
- Insurance ID Number
- Date of Service
- Other coding
If a mistake was made ask the insurance company or health care provider to correct it and resubmit your claim.
3. Compile Medical Evidence
Gather all the evidence to show that the services you need covered are medically necessary. Referrals, prescriptions from your doctor and any relevant information about your medical history may help your claim get approved the second time around.
4. Proper Paperwork is Important
If you need to write a letter to your insurance company make sure to include the correct claim number and the number on your health insurance card. Also, check to see if you can use standard insurance company appeals form, it will speed up the process. Your insurance company should give you information about this. Don’t limit your documents to forms. Provide as much relevant documentary evidence as you can.
5. Keep a Paper Trail
Keep track of all your paperwork and take careful notes during every phone call with the insurance company. Record the name and the job title of the person you’re speaking to and write down the date of the conversation and any next steps. In addition, ask for a “call reference number,” and if an appeal was submitted, get the “document image number.” This information will help you build your case as well as move the appeal process forward.
6. How to Accelerate the Process if Needed
It’s the law, you can file an expedited appeal if the timeline for the standard appeal process would seriously jeopardize your life or your ability to regain maximum function. In such cases, file internal and external appeals simultaneously. If you’re too sick to take care of this on your own, your doctor can file an external appeal on your behalf.
Our clients benefit from having someone on their side who understands the complicated appeal process and is skilled at navigating it. Last resort, file suit.
To talk with a lawyer you can trust about fighting your health care claim visit us at www.erisaattorneys.com, or call us at 617-934-7488 or toll-free at 866-406-9783. Your initial consultation is free.