You may be lucky to have never experienced any form of medical claim denial, but that does not mean similar scenarios are in existent. Many people have fallen victims of claim denial with their medical insurance. As a result, preparedness becomes a vital component should such an event occur to you. Detailing below is a list of 5 best and easy ways to observe while handling a medical claim denial.
Contact Consumer Assistance Program
Abbreviated as CAP, Consumer Assistance Program is a platform that aids consumers having health insurance problems. Since this may be a new occurrence, and you do not know how to go about it, the first step becomes contacting the CAP. It will offer guidance on the steps to follow, which are ideally what will become discussed below. In a situation where your state does not have the CAP services, it is recommended you seek help from your state insurance regulator.
File an Internal Appeal and Wait for a Decision
All health insurance, thanks to the Affordable Care Act, are entitled to an appeal process, which is the second step of handling a medical claim denial. It involves completing all documentation required by the health insurer and submitting the information you want to become considered. However, this should be within 180 days after being offered the denial. A decision of the appeal becomes availed within 30 days.
Identify the Type of Denial is Open to an External Review
The internal appeal may turn out unsuccessful. In this case, you need to consider the external appeal. Before opting for the external appeal, you will need to conduct an evaluation. The aim is to discover if the specific denial if open to external review as not all denials stand a chance of external reviews. The three main denials open to external review are denials where:
- Medical judgment where client disagreed with the insurer
- Treatment is experimental or investigational
- Cancellation of coverage with claims that information was given was incomplete or false
Ask and Pay for an External Review
One certain that your denial is legible for external review, the next step is to ask for an external review. However, this is not done for free thus; you will need to pay for the services of conducting an external review. Most external review programs charge an estimated $25 per review. Essential to point out is that the review must be within the standards of your states CPA
Consider Bringing a Lawsuit and Hiring a Lawyer
Within 60 days, a decision should have been availed with regards to the external review conducted. Although the process can successfully be in your favor, at times, things may not turn out as expected. In such a case, you need to file a lawsuit and hire a lawyer to handle the matter in court. Most of the times, especially if all the facts of the denial claim are just, the court will legally favor your case. Therefore, you need not panic or act irrationally upon receiving a medical claim denial.