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What to Do If Your Health Insurance Claim Is Denied

Having your health insurance claim denied can be stressful. But just because your insurer refuses to pay for your treatment or services doesn’t mean you need to rush to take out a loan or tap into your retirement savings. When your insurance company won’t cooperate, it’s important to keep in mind that you have options. Read on to learn about the steps you can take to get the healthcare coverage you need.

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Find Out Why Your Claim Was Denied

If your health insurance claim is denied, it’s a good idea to contact your insurance company and find out what happened. Inaccurate information or missing details could lead an insurer to reject someone’s claim. Your insurance company could also refuse to pay for a procedure if it isn’t covered under your insurance plan or you wait until the last minute to file a claim.

Seek Help

What to Do If Your Health Insurance Claim is Denied

Once you find out why your health insurance claim was denied, consider asking your doctor or hospital for help. They can potentially offer some support since they’ve likely dealt with your issue in the past. For example, your doctor or nurse may be willing to advocate for you if your claim was denied due to a clerical error.

Talking to a hospital worker may be another good step to take. Hospital social workers specialize in helping patients get coverage for the treatments they need. If you aren’t eligible for certain benefits, a social worker may know a charity that can pay for your medical expenses.

If your claim was denied because your insurer deemed a certain procedure unnecessary, getting the company to reverse its decision may be more complicated. Your doctor may need to write a letter explaining that your treatment or procedure was medically necessary.

Related Article: 10 Health Insurance Terms You Should Know

Appeal Your Insurer’s Decision

If your insurance company denies your health insurance claim, keep in mind that you have the right to appeal their decision. The appeal process may vary depending on your insurer and their company policy. But generally, you’ll need to contact your insurance company and ask them to review their decision regarding your claim. For anyone who purchased a health insurance plan through the government’s marketplace, this process is known as an internal appeal.

In order to file an internal appeal, you may need to submit a series of documents. For example, you may need to provide a doctor’s note and detailed information about the treatment or services your insurance company didn’t cover. If the internal process doesn’t resolve your problem, you can try to request an external review within 60 days after your insurer rejects your claim for the second time.

During an external review, a third party looks into your case. If it rules in your favor, your insurance company is legally obligated to honor their decision. If your claim is rejected a third time, you won’t be able to go through the appeal process again.

Related Article: What to Do When Your Homeowners Insurance Claim Is Denied

Final Word

What to Do If Your Health Insurance Claim is Denied

If your health insurance claim is denied, being proactive can put you one step closer to getting the coverage you need. As you try to resolve your problem, it’s a good idea to save any correspondence you receive and keep detailed records of the conversations you have with your insurance company. That way, you can avoid miscommunication and provide proof of the steps you’ve taken.

Photo credit: ©iStock.com/Makidotvn, ©iStock.com/daizuoxin, ©iStock.com/undrey

Jennifer Stinnett Jennifer Stinnett writes about a variety of personal finance topics for SmartAsset. Her expertise includes retirement, taxes and home buying. Jenniferhas a degree from Florida State University in English with a focus on Editing, Writing and Media.
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