| Medical insurance claims are denied for all sorts of | | | | the phone. |
| reasons. What do you do if you feel the insurance | | | | 4. If you do understand the reason, but disagree, call |
| company should have paid on a claim but has denied | | | | the insurance company. Explain why you disagree to |
| it? | | | | the representative and ask what it will take to get this |
| Having run a medical billing service for twelve years, | | | | claim paid. |
| we've see a lot of denials on claims. The biggest key | | | | 5. If the claim has been denied for a reason which can |
| to getting a claim paid when it is denied incorrectly is to | | | | be remedied, ask the representative exactly what you |
| act on it immediately. Sometimes in a busy medical | | | | must do to correct the situation. If you are the patient |
| office, there is a tendency to put a denial in a pile or | | | | or calling for the patient, this may involve calling your |
| drawer or take care of it later, but this is a mistake. | | | | doctor's office and explaining to the billing manager |
| The sooner the problem is dealt with, the more likely | | | | what you have found out and asking them to follow |
| you are to get the decision reversed and the claim | | | | through. |
| paid. | | | | 6. The representative may tell you that the claim has |
| Here's how: | | | | been denied correctly. That does not necessarily mean |
| 1. Look the denial over carefully. Look for a denial code | | | | that they will not pay. The claim may have been |
| that may be numbers or letters or a combination. Now | | | | denied for timely filing. If the billing office resubmits the |
| search for the explanation of the denial codes, | | | | claim with proof of timely filing, the decision may be |
| sometimes found at the bottom of the remittance. It | | | | reversed. (Incidentally, if the claim is denied for timely |
| may not make sense to you, but that does not matter. | | | | filing, the patient cannot legally be billed.) The claim may |
| Right now you just want to know their reason for | | | | have been denied for incorrect ID#. In this case, the |
| denying the bill. | | | | ID# is corrected and the claim is resubmitted. |
| 2. Once you determine the insurance company's | | | | 7. If you cannot get a solution to your problem with a |
| reason for denying a claim, you have a better idea of | | | | phone call, it may be necessary to file a written appeal |
| what to do. If the reason makes absolutely no sense, | | | | to the insurance company. Ask the representative |
| call the insurance company. There is usually a phone | | | | where you should send your written appeal. Explain |
| number on the denial form. Calmly explain the situation | | | | your situation entirely and the reasons you feel this |
| to the customer service representative. These | | | | claim should have been paid. Keep copies of all |
| representatives have to deal with calls like this all day, | | | | correspondence and notes of all telephone |
| so it is much better to treat them respectfully. | | | | conversations. Write down who you spoke to, when it |
| Remember, if a mistake was made, it wasn't this | | | | was, and what they told you. |
| person who made it; they are going to correct it for | | | | Whether you are an individual trying to get your |
| you. Be nice. | | | | medical bill paid or you are from a doctor's office, |
| 3. If you don't understand the reason at all, call the | | | | make sure you keep good notes of everyone you talk |
| insurance company and ask for an explanation you do | | | | to or write concerning the problem. This can be the |
| understand. It is very common for an insurance | | | | key to getting your claim paid. If you are an individual, |
| company to deny a claim incorrectly or because there | | | | get the doctor's office involved in helping you with your |
| was not enough information on the claim form. If they | | | | problem. Many times they know who to speak to or |
| have denied the claim incorrectly, many times the | | | | how to handle the problem. |
| representative can fix the problem while you are on | | | | |