What would you do if your health insurance company refused to cover the tests, treatments, or medications your doctor said you needed? states that the right to appeal is guaranteed. And the good news is that it shouldn’t be too difficult to do.
About 18% of in-network claims from insured persons through Affordable Care Act plans were denied in 2020, according to a Kaiser Family Foundation report.
But that doesn’t mean you should pay for treatment yourself right away. Consumer Reports says you have the right to appeal the decision, which applies to Medicare or private health insurance.
first step: Call your insurance company to make sure your claim is correct. Mistakes can and do occur at multiple points in the claim submission or pre-approval process, and once identified, they are often relatively easy to correct.
If you’re not mistaken, ask the reviewer behind the decision to talk and ask for clarification. You will need this information in the next step. That is, file a formal appeal clearly stating that you do not agree with the decision.
Ask your doctor to write you a letter explaining the need for the procedure. They are used to this, so don’t be afraid to ask. Gather as many copies of other supporting documents as possible, such as medical records, treatment studies, and previous correspondence with insurance companies.
next step Perhaps the hardest: waiting. It may take him 30 days or more to get an answer, but if you need the denied treatment immediately, request expedited review.
If you receive a letter that the insurer still chooses to deny the claim, both Medicare and the private insurer should provide reasons in writing and make a decision for independent third-party review. We are required by law to tell you how to appeal.
If you get insurance through your employer, consider asking your company’s human resources department for help. If your claim is denied by Medicare, you may consider getting legal help to hear your case before a judge.
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