What to Do When Insurance Doesn't Pay Claims?

Errors sometimes happen when a medical provider bills for services or supplies. Even a simple mistake like entering an incorrect medical code can result in a claim denial by the insurance provider. When this happens, there are steps you can take to resolve the problem. Start by bringing the issue immediately to the attention of the party responsible for billing the charges.

Knowing Your Plan

• Reading your benefits manual can help you understand your rights and responsibilities. The plan policy should outline in detail the medical conditions and services the insurance company will and will not cover. In many cases, denied claims arise because people don't know what their policy covers. If you still have questions after reviewing the terms of your policy, contact your health plan administrator for clarification.

Internal Appeals Process

• Talk to your doctor or the hospital billing office and explain that the insurance company denied paying your claim. If you must appeal the insurance company's decision, contact the insurer for instructions on how to initiate the process. Most health insurance plans allow you 60 days from the date of denial to file an appeal. The appeals process can differ among companies, but all require you to file a written appeal. If your insurance company still refuses to reverse the decision, you may have to file an external appeal.

External Appeals Process

• In the event the appeal to your claim fails, the next step is to file an appeal with your state's department of insurance. Contact your state insurance commissioner to find out how to go about the process. Normally, you will take your case before an independent board of professionals knowledgeable about insurance claims. The board will hear what you have to say and then make a decision regarding your claim. If the board members decide in your favor, the insurance company must pay the claim. In cases where an employer pays 100 percent of all claims, a state laws governing insurance companies do not apply.

Under the Law

• Insurance companies subject to federal and state laws must provide you with certain information if your claim is denied. The company must summarize the specific medical reason causing the denial. If the plan has a provision that excludes a particular medical treatment, the insurance company must clearly identify that provision. The company must then provide a description of any alternative treatments, services or supplies that the plan does cover. State laws mandate that an insurance company must provide you with the name, medical license number, licensing state and title of the individual who denied the claim.