You pay for health insurance to protect you and your family. Even as you hope that you will never need it, you still hope that your insurer will be there for you when you’ll need it. When that time of need comes, most people are hit by the painful reality that insurance companies exist to make money. Instead of helping the insured in their time of need, they strive to find loopholes so that they can delay, underpay, or deny claims. If your life insurance or health insurance has been unjustly denied, you’ll be relieved to know that insurance denials can be reworked and resubmitted.

Stop Health Insurance Denial is the logical choice for policyholders all over the United States, who’ve been denied health insurance coverage. We are an industry-respected law firm that has handled different types of insurance denial cases. With us on your side, there will be no reason for you to be intimidated by your insurer. We have competent lawyers who will sort out all the details of your case and present a solid case on your behalf.

5 Common Reasons for Insurance Denials

Understanding why your health insurance claim was denied is a vital aspect to knowing whether you can go ahead and appeal the health insurance denial. The following are the reasons why health insurance claims get denied:

  1. Invalid patient identifier information

Missing or incomplete information in the submitted claim documents often results in insurance denials. Some of the commonest mistakes that can result in insurance claim denials include:

  • When your name in the insurance claim is misspelled, or doesn’t match the names in the insurer plan’s system,
  • The date of birth in the insurer plan’s system does not match the date of birth on the claim,
  • Your insurance ID number is in invalid or missing from the claim,
  • Your group number is invalid or missing,

In case any of the above errors occur, the insurer cannot identify the patient to make compensation. It is, therefore, crucial to supply the pertinent information, including the correct patient identifier information when filing a medical claim.

  1. Non-covered, excluded or terminated services 

Different plans cover different issues. At times, even though one part of a medical procedure may be covered because of medical necessity, various parts of the series of medical tests or procedures your doctor may recommend based on your health condition may not be covered by your health insurance plan. An insurance company may deny your insurance claim if:

  • You have exceeded the coverage limits in your health insurance plan,
  • Your health insurance coverage has terminated,
  • The therapy or drug is off-formulary,
  • You use your health insurance out-of-network, while your health insurance plan requires that you only use “in-network providers”.

For non-covered or excluded services, you will have to pay 100% for them. Therefore, it is important to contact your insurer beforehand to confirm that your insurance coverage is active and that it covers the services that you seek.

  1. Lack of prior authorization 

It is customary for most insurers to require prior approval or precertification for non-emergency-related and costly health care services. Such health care services include expensive radiology services such as MRI, CT, and ultrasound. Certain inpatient admissions and surgical procedures may also require prior authorization by the insurance company. Therefore, claims made after obtaining such services without obtaining prior authorization depending on the insurer’s guidelines will likely be denied.

  1. Invalid HCPCS, ICD or CPT codes

There are 3 different insurance coding systems, which include the Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD), and Current Procedural Terminology (CPT).  The HCPCS, ICD and CPT codes help to match health conditions to healthcare services given. They were developed to ensure that there is a reliable and consistent way for insurers to process claims from healthcare providers and make payments for the healthcare services they provide to policyholders.

It is possible for your doctor to use the wrong codes for the services you obtained. This can be either coding the wrong procedures or the wrong diagnosis. Simple typographical errors can trigger significant consequences, insurance denials being one of them. Should your doctor use invalid HCPCS, ICD or CPT codes, your insurer may deny your claim.

  1. Untimely filing

Insurance companies always define their own time frame during which claims must be put forward for consideration. Filing deadlines often range from 90 days to 1 year from the date of health care service. Failure to submit an insurance claim within the stipulated period often results to insurance denials.

Those are the commonest reasons for insurance denials. Be sure to determine the reason(s) why your insurance claim was denied. Before appealing a health insurance denial, it is best to contact your insurer and seek information that can help you understand more about your health insurance policy coverage.

How to Appeal a Health Insurance Denial

Battling your health insurer after it denies your insurance claim can be frustrating and time-consuming. Each situation is different as some health insurance coverage problems – such as wrong code entry – can be easily resolved with a phone call, while other issues can be more complex. With the right law firm representing you, the right information and the right approach, you can successfully obtain all the benefits you are entitled to. The following are the steps to take when appealing a health insurance denial:

  1. Review the denial letter from the insurer

Primarily, you will need a copy of your denial letter, which will be sent by the insurance company. One of the things that will be clearly outlined in the letter is/are the specific reason(s) why your health insurance claim was denied. The letter will also provide a customer service telephone number, which you can use to call the insurer if you require an explanation about the denial of your insurance claim.

If your coverage clearly stipulates that the service you obtained is not covered, you already surpassed the limit for a health insurance coverage, or you were out of network, then it won’t make much sense to file an appeal. The assistance of an attorney is crucial here as it can be easily determined whether you have grounds for making an appeal or not.

Once you decide to go ahead with the appeal process, it’s best to review the details of your insurer’s appeals process, including the deadlines. This information will also be provided in the denial letter. If you happen to miss a deadline, you will waive your right to file suit or appeal to reverse the claim denial.

If the insurer has not provided information regarding their appeal process, you can call them to request this information. When contacting the insurer, be sure to take detailed notes, including the date and time of the call, the length of the call, the name of the customer care person you talked to, and other important details of the conversation.

  1. Study your health insurance policy

Do you know what you are entitled to and for what? You cannot know what you are entitled to or not entitled to if you do not know the contents of your health insurance policy. So, you should request a copy of your health insurance policy from your insurer and review it thoroughly. The section that you should especially want to read exhaustively on is the one that defines allowable claims and coverage. Attorneys at Stop Health Insurance Denial will review the exact language of your insurance policy and find support for an appeal.

  1. Gather evidence to support your appeal

Gather crucial information that will help support your claim. One of the helpful materials that could serve as evidence is a letter of support from your healthcare provider or doctor. Ask your doctor to write a letter that explains that the healthcare services you received were medically necessary. The doctor should also provide you with relevant resources supporting the application of the treatment to your health condition or illness. You can also look for journals or articles that describe your condition or illness and support your doctor’s conclusions.

  1. Write a strong appeal letter

Write a strong appeal letter that clearly explains your health insurance claim. Be sure to give a description of your medical condition and how your life has been affected by it. You should also explain your justification for believing that your health insurance claim should be covered. Be sure to refer to the specific sections of your insurance policy. Also be sure to provide your contact data and that of your doctor to enable the insurer to contact you if they need further information. An attorney from Stop Health Insurance Denial can help you write a strong appeal letter.

  1. Submit your appeal package

Make a copy of your appeal letter to save for your own reference. Take one copy and then send it together with whatever evidence you have to the insurance company. When submitting your appeal package, be sure to follow the instructions provided by the insurer regarding where to send your appeal package. It’s best to send your appeal by certified mail with a request for a return receipt. Most appeals take weeks or months. Be sure to follow up with your insurer and call regularly to check on the status of your case.

What Not to Do When Appealing a Health Insurance Claim

  • Do not submit your appeal package before evaluating your health insurance policy and claim file.
  • Do not submit just the written letter. Present the letter along with supporting documentation from your doctor, medical records, and supporting medical articles and journals.
  • Do not send your appeal package by regular mail. Send it by certified mail and request for return receipt. This is to ensure that the package arrives to the right place and to give you proof of delivery in case of any dispute.
  • Do not make all communication with the insurer by phone only. Be sure to make communication in writing, fax, or email as well.
  • Do not miss the deadline to appeal. Failing to appeal within the stipulated deadline means that you relinquish your right to pursue the claim any further.

What to Do If your Appeal Is Denied

If your appeal is denied, call Stop Health Insurance Denial to file a suit in federal court. Your legal claim in court will generally be based on the argument that the insurance company acted in bad faith. To make this argument, your attorney will need to prove one or more of the following:

  • The insurance company failed to respond to your health insurance claim on time,
  • The insurance company acted improperly in turning down your claim,
  • The insurance company failed to adequately investigate the facts surrounding your health insurance claim.

Hiring Stop Health Insurance Denial means that you won’t have to fight the insurance company that has denied your claim on your own. At this critical time in your life, we understand how crucial it is that you have reliable health insurance coverage. We have engaged in court battles with major insurance across, so we are confident to win your battle. We will work tirelessly to ensure that your insurers get to pay for what you rightfully deserve.

How Long will it Take to Secure the Compensation?

The duration of time it takes to secure compensation varies considerably depending on various factors. One of the factors is where you live. While specifics vary from state to state, majority of the states require insurers to pay compensation within a “reasonable time”. These states have regulations that protect policy holders by setting a timeframe for how promptly an insurer must acknowledge a health insurance claim, investigate it, and make a fair compensation. This is usually within 30 days after a settlement has been reached.

As soon as you file a health insurance claim, ask the insurance claims expert how long it will take to secure the compensation you seek. That way, you will have a realistic set of expectations about when you will get paid. If your insurer has refused to honor your claim or has failed to offer the payout you rightfully deserve in a timely manner, you may be a victim of insurance bad faith. Attorneys at Stop Health Insurance Denial are well-versed in insurance law and can assist you to get your compensation in a reasonable amount of time.

How to Speed Up the Claims Process

Even though insurers only have to respond to insurance claims as quickly as state regulations require, there are ways in which you can speed up the health insurance claims process. One of them is being prepared with as much information as possible when making your claim. This includes supporting documentation from your doctor, medical records, and supporting medical articles and journals.

Another way you could speed up the claims process is by quickly completing all requested paperwork. You should also promptly respond to phone calls, mails and emails from the insurer concerning your claim. You’ll also get to speed up the claims process by hiring an attorney. By hiring a highly competent attorney from Stop Health Insurance Denial, your case will be handled expertly and there will be no room for errors or mistakes. This will ultimately lead to a fast approval of your claim.

Questions to Ask in a First Meeting with an Attorney

Before meeting an attorney for the first, you should prepare a list of questions. How the attorney responds to these questions is what will enable you to know whether you will feel comfortable working with that particular legal professional. Some of the questions to ask include:

  • What services do they provide?
  • Have they handled cases that are similar to yours before?
  • How many cases have they won?
  • Are they readily available during the case?
  • How can you reach them?
  • What do they expect you to do during the case?

Attorneys at Stop Health Insurance Denial can answer any questions you may have about filing a health insurance claim. If you have any questions about how long it should take you to obtain the compensation you rightfully deserve for your claim, be sure to contact our legal team for further assistance.

Why It’s Necessary to Have Legal Assistance

The importance of having legal assistance when pursuing a health insurance claim cannot be overemphasized. In a variety of circumstances, the representation of a competent attorney can make a huge difference in holding insurers accountable for the obligations they are indebted to their policy holders.

Attorneys at Stop Health Insurance Denial understand the intricate legal requirements that insurers companies are required to comply with. As such, we can help to make sure that you are not misled or taken advantage of by your insurer. Whether you are looking for help with filing your initial claim or filing a bad faith insurance claim, we can help.

Finding a Health Insurance Appeal Attorney Near Me

You do not have to deal with an insurance company that uses deceptive practices to make insurance denials. If your insurance company has wrongfully denied your health insurance claim, our experienced attorneys at Stop Health Insurance Denial may be in a position to help. We are dedicated to serving policyholders all over the United States, who think that they might be victims of insurance companies acting in bad faith. Find out more about your legal options in this unsettling situation by calling 310-695-5241.