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Disputing A Denied Healthcare Claim
It is not unusual for a health insurance claim to be either partially or fully denied. If this happens to you, consider the following approach to dispute a denied claim.
1. Contact your insurer and ask that a claims adjuster review the denial and explain the reason for the denial. Ask how the issue can be resolved and the claim processed and paid. It may be as simple as a wrong diagnostic code being entered. Be sure to keep a record of your call including date, time, who you spoke to and what was discussed.
2. If talking to the claims adjuster does not solve the problem, ask for a formal claim review to be initiated.
3. Seek help from your human resources department if your healthcare coverage is purchased through your company. They may be able to intervene to solve the problem. You might also ask your doctor’s office if they can contact the insurance company to try to solve the problem and explain why you needed the care.
4. If you are still not having any success, write a formal letter to the claims manager explaining why you think the claim should be paid, and request a response by a certain date.
5. If still not satisfied, send copies of the letter you wrote to the claims manager to their superiors, such as the regional vice president of claims. Call the insurance company to get names, titles and addresses of people you should contact.
6. Finally, if your insurance company still declines to pay the claim, and you feel it should be covered, contact your state insurance regulatory agency. Contact information can be found at NAIC.org.
Finding The Right Health Insurance Plan
Although health insurance companies are regulated by your state insurance commission, their rate structures vary widely, even for individuals with identical health and risk profiles. So, it pays to shop around for the best rates for equivalent coverage, which could easily save you hundreds or thousands of dollars annually. Unfortunately, comparing health insurance plans is much more difficult than comparing homeowner’s, automobile or life insurance plans, since the variables in coverage are much greater. Also, your ability to qualify for insurance coverage also has many more variables. With that in mind, try the following approach to locate affordable coverage that is right for you.
1. If possible, meet with two or three of the major health insurance companies such as Aetna or Humana.
a. Work with these companies to figure out what coverage is right for you.
b. Once you decide what coverage you want, get a quote from each of the companies based on this coverage.
2. Using the coverage descriptions discussed above, contact other major health insurance companies and get a quote. But make sure the coverage is equivalent, or that you understand the differences.
3. Using the coverage descriptions, contact two or three independent insurance agents to get quotes. Independent insurance agents generally represent several different less well known, but reputable, insurance companies that may offer better pricing.
4. Using your coverage descriptions, go to the Internet and apply for coverage with some of the better known insurance companies that sell over the Internet to get a rate quote. You may also want to visit sites like eHealthInsurance.com or Insurance.com where several insurance companies are represented, and rates can be compared.
5. Now that you have decided what types of coverage you want, and have found
a lower-
a. Because of state regulation, it is rare that an insurer will fail and not be able to pay your claim, but it does happen. So if you have decided to deal with a less well known insurer, and they are represented by an independent insurance agent, have that agent demonstrate to you that the insurer is financially secure. This will generally be done by showing the rating an insurance company has received from an independent insurance rating agency. If the company is not represented by an independent agent, or you are still concerned, call the State Insurance Commission to inquire and/or do some research on the Internet at insurance company rating sites like Moodys.com and AMBest.com.
b. While the company you are considering may be financially solid, they may or
may not have a reputation for settling claims in a hassle-
6. Now that you have chosen your insurance company, you may keep your insurance policy for many years to come, assuming you do not accept employment where more affordable health insurance is offered. However, if your health continues to be good, you may want to shop around every few years to see if a better price and coverage is available from another company. If so, inquire with your insurer to see if they can make a premium or coverage adjustment. Do not drop insurance until you have new coverage in effect.
HEALTH INSURANCE -
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