How to Appeal Denied Claims

Thursday, 18 March 2021

Denied Claims
When it comes to health insurance claims, there are so many moving parts that it can be difficult to keep up. Let’s say you went in for a surgery, and weeks later, you’re hit with a massive out of pocket bill. You find yourself confused and frustrated because you took all the necessary steps to insure this would not happen; you made sure your provider was in network and you even went the extra mile to make sure your procedure was covered by your insurance carrier.

So, what’s the #deal?!

Before you start making phone calls, let’s breakdown the relationship between the operating doctor, the insurance company and you, as the client, so you can get to the root of the problem quickly.

The doctor’s main job is to provide good ole’ fashioned TLC! Their focus is to treat you and make sure you have everything you need from a medical standpoint.

The insurance company’s role is to interpret the contract between them and the doctor and pay out claims based on the contractual language.

Your job, as the client, is to simply receive care and make sure you have everything needed to recover!

When there’s a #breakdown in #communication between these three parties, that’s when the processing of claims can turn a little #wonky. Sometimes because of this breakdown, claims get denied, which is why you may be receiving that surprising out of pocket bill. Based on the situation, this could be a false denial!

The good news is, that if you don’t agree with the denial of a claim, you can #appeal the insurance company’s decision!

In order to start the appeal process, you’ll need to call the number on the back of your health insurance ID card and tell the representative to open an appeal on this claim. During the appeal process, the insurance company will analyze all of the facts by getting the doctor and you involved in order to determine if the claim was processed correctly.

Depending on which insurance carrier you are with, the appeal process can take anywhere from 30-60 days. At this point, the insurance company will reach its final decision to either reprocess the claim or remain firm on their original stance.

If you have any other questions regarding denied claims or the appeal process, give Clevenger Insurance a call today at 574-267-2181!

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