The very nature of managed care health insurance plans will increase the chance of a legitimate health insurance claim being denied. Keep in mind that managed care (health maintenance organizations, or HMOs, and most well-liked supplier organziations, or PPOs) exist for the purpose of controlling costs for the health insurance company. Many health care procedures, surgeries, sturdy medical equipment and medication, particularly the more expensive ones, require previous authorization from the health insurance arrange before the arrange can pay. Claims are reviewed to see "medical necessity" of the claim. Health care services or product deemed "not medically necessary" will almost definitely be denied for payment by the health insurance plan.
Health insurance companies do create mistakes, however, and it's definitely doable that a coated expense can be denied. What recourse will the health arrange member have when one disagrees with the choice of the health set up? Here are some steps to take in addressing a denial of payment.
1. Review the reason of advantages (EOB) sent to you from the health insurance company. The EOB should state what services or goods were billed and briefly why advantages were denied.
2. Review your specific health insurance policy. What benefits does the health insurance policy state for the actual service or product? Ought to the claim be coated per the policy?
3. Will the health plan have special criteria to be met in order for an specific expense to qualify as "medically necessary" and be thought-about a covered expense? For example, many managed care plans can cowl medication on their formulary. Other, nonformularly drugs may not be lined in any respect, or may be coated solely if the formulary medicine are tried and failed. An upscale MRI procedure could only be lined if sure symptoms are present. Check your policy to see whether or not the expense qualifies as "medically necessary" by the health insurance company. Your health care provider should submit sufficent documentation to the health insurance set up to justify the need for the expense.
4. Is that the health care supplier "in-network" (contracted) with your health insurance plan? If not, will your managed care plan cover "out-of-network" (non-contracted) providers? Most HMO plans don't cowl "out-of-network" providers; several PPOs can pay for services by "out-of-network" providers, but typically at at lower rate than paid to "in-network" providers.
If, after reviewing the health insurance policy and also the EOB, you feel that the claim should have been a coated benefit by the insurance company, you must initial request in writing that the insurance company give you with the knowledge that they used to base their denial of benefits. The health insurance company is needed to produce you with this data on request. Review this info carefully. Many times the health insurance company wasn't supplied with acceptable or sufficient documentation from the provider to justify the claim. If this is the case, contact the provider and request that they submit more medical records that support the claim for benefits. It could conjointly be helpful for the supplier to put in writing a letter to support the claim additionally to the medical records. Your claim might be resolved during this manner.
All health insurance companies have a method in place by which set up members can attractiveness the choices of the health insurance company. If providing more documentation will not resolve the dispute, then an attractiveness must be filed with the health insurance plan. Your supplier may help you with this, and they may not. Read the member handbook and/or policy and follow the procedure for appealing the denial of the claim. Be ready to submit additional documentation to support your appeal. Keeping a record of all interactions with the insurance company is vital. Record all phone conversations and embody the name of the person you spoke with, a temporary summary of the conversation, and also the date and time. File all correspondence sent and received, and have it readily accessible.
Bottom line is that health insurance plans are "for-profit" entities; in business to make money. They appear for reasons to not pay. Indeed, their goal is to not pay, increasing their profits and keeping prices down for the members. It's up to you to ensure that legitimate claims for coated benefits are paid.
Author Resource:
Riley Jones has been writing articles online for nearly 2 years now. Not only does this author specialize in Health, you can also check out his latest website about:
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