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Guidandce To Appropriate Health Insurance Claim Process And Denial Appeals

Health insurance policy covers the medical and surgical costs of the insured person. At the time of paying doctor or hospital charges – 1. The insurer pays it out of their pocket and gets reimbursed by insurance providers later on. 2. The insurance company makes the payment directly to the health-care provider. However, in both cases you will have to submit a claim form to the insurance provider. Health insurance claim form provides the company details regarding the medical treatment situation that you have received. Here is step to step claiming process guidance. 1. Attain itemized bills – First request your hospital, clinic or doctor for itemized receipts. The list in the bills will have every details related to your treatment along with cost of each services. This is because you are required to attach original receipts and bills with the claim form. 2. Obtain the claim form – Now, you will need a health insurance claim form. This can be obtained from your health provider’s site. You will have to answer the questions like – what was the reason illness/accident, whom you have to make the payment, etc. Moreover, the form may also need some extra details from your health-care facility or doctor. 3. Keep record – Having Xerox copies of your form and itemized medical bills is very important. Having Xerox copies on record makes it easier to re-file the claim in case of papers getting misplace. 4. Review before sending – The claim form must be read minutely to make certain that every necessary field are filled appropriately. Even ensure that the necessary bills and receipts are attached. Once you find that everything is in order submit the form to your insurance provider. It takes roughly thirty days for claiming process to get completed. In case, you get a denial do not panic or ignore it. Many times denials are factual errors or simple coding for example the diagnosis does not fit treatment description, prior authorization was necessary but you did not ask about it, did not fill the right box, etc.


In case of health insurance claim denials 1. Contact the customer help desk – Call them and request for an explanation of being denied. You may not get desired answer on first try but ask them to let you talk to their supervisor. Keep asking till you get a comprehensible answer. Every staff member you ask, remember to note down the name of that person you speak to. Before hanging let the personal know that you are collecting evidence to resolve this problem. 2. If it is the health-care providers mistake – If the insurer says that it is your hospital or doctor’s mistake then you can have it corrected by the related facility. Thus small coding errors can be corrected and resubmitted. 3. In case of ‘not medically necessary’ – Sometimes according to the insurance provider your request for reimbursement was ‘not medically necessary’. The clinical policies are difficult to decipher but can be understood by your doctor. You can print the clinical policies available online. This will help the health-care provider and they will fit the claim more precisely to your requirements. 4. Re-file your claim – According to the Health Reform Law – 2011, insurance companies has to provide forms to appeal again for denial claims. There are 50/50 chances to attain the health insurance claim. Yes, it is the effort and time that is necessary to pursue this issue. The bottom line is – grab the opportunity to win but take time and correct your errors in the claiming form.


Guidance to appropriate health insurance claim process And Denial Appeals