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How Do I Appeal A Health Claim?

Oct 22, 2007
Health insurance claims can be appealed by submitting the proper forms to your health insurer. If a claim is denied or paid incorrectly, in your estimation, every health insurer must allow you to appeal how the claim was paid.

Your appeal may be denied but the health insurer must allow you to appeal the claim. An appeal is near the end of the process for claims being denied or paid incorrectly. There are some other steps in advance of a health insurance claims appeal that can be completed to attempt to get the health insurance claim processed.

Initially, you should contact your health insurer's customer service department and speak with a customer service representative. Provide the customer service representative your member identification number and the date of service for the claim. If you ask questions of your plan, you may be able to uncover if the claim was paid incorrectly and avoid the appeals process. Be sure to have read your summary plan description or certificate of coverage so that you are armed with the proper information about your plan.

If your conversations with the health insurer do not provide satisfactory results, you would then turn to an appeal. Health insurers must follow state and federal laws regarding consumers and their right to appeal medical claims. Health insurers have dedicated staff members who are on an internal appeals committee or an internal review committee. Their job is to interact with consumers and provide a conduit for claims questions and ultimately an appeal.

Many states require an external review procedure whereby a review committee comprised of non-employees reviews claims. External review committees review claims for consumers and make decisions about the claim and how the health insurance claim should be paid by the insurer.

The entire process of appealing a health care claim can be daunting. Check with your states' department of insurance to get more information on your health insurer's responsibility in your state. You should also know how your health plan works and what your benefits are so that you can make a good argument about the claim. Health insurers will work with you to resolve claims as long as the claim is reasonable and within the plan requirements of the health insurance plan with which you are enrolled.

Be sure to create a folder to maintain copies of all the communication you send to a health insurer and the communication sent to you from the health insurer or external review committee. This process is not an overnight ordeal and can be challenging, especially if you or a loved one is in the middle of treatment for a serious health condition.
About the Author
Scott is a partner in ESP Benefit Design, an employee benefits insurance firm based in Westerville, Ohio. (614-882-8535) Scott has an MBA from Franklin University. Scott has worked with over 6,000 customers. Email Scott at scott@espbd.com

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