Denied Claim - 7 Steps To
Get It Paid
When you have a denied medical claim and you feel
the insurance company should have paid that claim what should you
do? Medical insurance claims are denied for all sorts of reasons.
Having run a medical billing service for
14 years, we've seen a lot of health insurance denials. The biggest key
to getting an insurance carrier to pay a claim when it is denied incorrectly is to act on it
Sometimes in a busy medical office, there is a tendency
to put a denied claim in a pile or drawer or take care of it later, but this is
a mistake. The sooner the problem is dealt with, the more likely you
are to get the decision reversed and the claim paid without an insurance appeal letter written.
Look the denied 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 insurance claim.
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
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. Tell them you are checking on a medical claim and 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
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.
5. If the denied 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
to get the codes paid.
you cannot get a solution to your problem with a phone call, it may be
necessary to file a written insurance appeal. 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.
If you have to write a health insurance appeal letter, be sure to keep a copy. Just write an explanation of the situation and your reasons you feel the claim should be paid. Many health insurance denials are overturned with an insurance appeal letter.
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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