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July 2022
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If your healthcare claim was denied due to an administrative issue such as a coordination of benefits, you may be able to correct the situation yourself. These kinds of mistakes often arise when a patient has a temporary overlap in healthcare insurance coverage, usually due to a job change. If a healthcare claim was denied simply because a provider unknowingly submitted it to your previous carrier, your provider can appeal by explaining this to the healthcare insurance company and providing proof of timely filing for the original healthcare claim. Appealing Out-Of-Network Treatment DenialsAppeals may be necessary for out-of-network care. Although in-network providers can submit an appeal for you, an out-of-network doctor cannot without your assigning your appeal rights to that provider. In these circumstances, you might request a letter from that provider indicating the necessity for the treatment and covering any other clinical discussion. Since these appeals often require significant clinical support and argument, it may be helpful to work with an experienced medical bill dispute advocate who is familiar with the process and knows what documentation to provide. Medical Necessity DenialsIf your healthcare insurance claim was denied based upon lack of medical necessity or for it being an experimental/investigational treatment, and all internal appeals have been exhausted, you can escalate your dispute through an external appeal. This means that an organization of independent doctors will peer review your case and determine whether the healthcare insurance company should have processed the healthcare claim under your policy. Appealing Covid-19 Healthcare Insurance DenialsIf you were issued a denial for your COVID-19 medical bill, contact your provider to see how they will be handling it. Many mistakes continue to be made in the way healthcare insurance companies are processing COVID-19 medical bills resulting in patients being charged for services that should have been covered. Some providers may be willing to fight a denial or COVID-19 overcharges for you — others may put the responsibility on their patients to dispute the processing of the healthcare claim directly with the healthcare insurance company. The Healthcare Insurance Denial Appeal ProcessA healthcare insurance denial appeal case must be handled systematically and pragmatically. No matter how well written, healthcare insurance companies will not respond any more favorably to an emotional appeal. The focus of an appeal should be solely on the facts concerning why your appeal should be granted, citing references and any correlating documentation. Often, healthcare insurance companies uphold their original decisions and deny first appeals outright to avoid making payment. A second level appeal may be given more attention. However, at the second level, you cannot merely re-state the argument in your first appeal. Rather, you must provide further documentation to support your position such as medical journal peer review articles or doctors’ letters. There are strict deadlines associated with filing appeals. These deadlines will vary by insurer and policy. For a first level appeal, most policies allow 180 days from the date of the EOB denial to file the appeal. A second level appeal usually needs to be filed within 60 days of the first appeal denial. Sending in a late appeal can result in your waiving the right to file one. Request That a Specialist Review Your AppealRegardless of the appeal level, it’s crucial to request a doctor in the specialty that you were treated be on your review board. For example, if your healthcare claim denial concerns neurology, you should request that a neurologist review the appeal. If not specifically requested, a doctor outside the specialty will likely be the one to make a determination on your healthcare claim. How Ajust Solutions Can Help with Your Healthcare Insurance Healthcare Claim Denial AppealIf you’ve received a healthcare insurance claim denial, an experienced medical bill dispute advocate can help. Ajust Solutions has been providing help with medical bills for over 30 years and knows what it takes to quickly and effectively negotiate even the most complicated medical bills.
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Even if your state has surprise medical bill laws, it’s still important to be aware of the measures you can take to avoid incurring them. Importantly, if you know that you’re going to require medical treatment in advance or require a specific procedure to be performed, make sure that the facility is within your healthcare insurance company’s network. It would be best to inform the facility in advance that you are only authorizing treatment by doctors contracted with your healthcare insurance, meaning only in-network and address any questions you may have concerning coverage with your healthcare insurance company. Additionally, while taking an ambulance may be unavoidable in some cases, it’s best to seek other forms of transportation — except in the event of a true emergency — to limit your financial liability, since ambulances often tend to be out-of-network with most healthcare insurance plans.
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