Denial of a Medical Claim - 7 Steps To Get It Paid

1.  Look the denial of the medical claim over carefully. Look for a denial code that may include numbers, letters, or a combination. Now search for the explanation of the denial codes, usually found at the bottom of the remittance. It may not make sense to you, but that does not matter. Right now you just want to know the reason for denying the claim.

2.  Once you determine the insurance company's reason for the denial, you have a better idea what to do. If the reason makes absolutely no sense, call the insurance company. There is usually a phone number on the denial form. Calmly explain the situation to the customer service representative. These representatives have to deal with calls like this all day, so it is much better to treat them respectfully. Remember, if a mistake was made, it wasn't necessarily this person who made it: they are going to correct it for you. Be nice.

3.  If you don't understand the reason for the denial of the medical claim, call the insurance company and ask for an explanation you do understand. It is very common for an insurance company to deny a claim incorrectly or because there was not enough information on the claim form. If they have denied the claim incorrectly, many times the representative can fix the problem while you are on the phone.

4.  If you do understand the reason, but disagree, call the insurance company. Explain why you disagree to the representative and ask what it will take to get this claim paid.

5.  If the denial of medical claim is for a reason which can be remedied, ask the representative exactly what you must do to correct the situation. If you are the patient or calling for the patient, this may involve calling your doctor's office and explaining to the billing manager what you have found out and asking them to follow through. Sometimes it is necessary to resubmit the claim.

6.  The representative may tell you that the claim has been denied correctly. That does not necessarily mean they will not pay. The claim may have been denied for timely filing. If the billing office resubmits the claim with proof of timely filing, the decision may be reversed. (Incidentally, if the claim is denied for timely filing, the patient cannot legally be billed.)

The claim may have been denied for an incorrect ID#. In this case, the ID# is corrected and the claim is resubmitted. The claim may have been denied for an incorrect diagnosis or procedure code. Often these can be corrected and paid when resubmitted properly. Another reason claims are sometimes not paid are because the codes are bundled. Here is more information on bundling  and how to get the codes paid.

7.  If you cannot get a solution to your problem with a phone call, it may be necessary to file a written appeal to the insurance company. Ask the representative where you should send your written appeal. Explain your situation entirely and the reasons you feel this claim should have been paid. Keep copies of all correspondence and notes of all telephone conversations. Write down who you spoke to, when it was, and what they told you.

Whether you are an individual trying to get your medical bill paid or you are from a doctor's office, make sure you keep good notes of everyone you talk to or write concerning the problem. This can be the key to getting your claim paid. If you are an individual, get the doctor's office involved in helping you with the problem of the denial of medical claim. Many times they know who to speak to or how the handle the problem.

The bottom line is that if a medical insurance claim is denied, it does not necessarily mean that the insurance company won't pay. It may involve following the proper procedures to get a desirable end result.

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