How to Keep Your Health Insurance Claim from Being Denied img

How to Keep Your Health Insurance Claim from Being Denied

It can be frustrating trying to deal with a health insurance adjuster after the insurer denied your recent health insurance claim. The problem inevitably becomes a wrestling match between you, the insurance company, and your health insurance broker. It can take several months for you to finally win your case or get compensation for your medical bills. 

The good news is that you can do some things to prevent the health insurance company from denying your claim. First and foremost, find a reputable health insurance broker in your state who can handle your claims and billing for you. Below, we look at six ways to keep your health insurance claim from being denied.

Make Sure Your Patient Information is Correct.

Insurance companies often deny claims because of incorrect or outdated information. So, Double-check that the information requested on the medical forms is correct when you are at the doctor’s office.

Make sure the following items are correct: 

  • Your name spelling
  • Contact information and address
  • Health insurance policy number
  • Health insurance group number
  • Name of guarantor
  • Date of birth
  • Medical information
  • Employer name and information

Double Check the Medical Codes

Health insurance claims processing software may reject codes that are incorrect, incomplete, not covered, or not relevant to each other. You may be asked where an injury occurred or what was involved, and you have to be specific. 

References to the body will distinguish between right and left and drill down to specific parts.  If your visit or service is denied, check whether the rejection is related to an incorrect or incomplete code and call the billing department. Be patient: Your medical information forms will be even more complicated in the future when providers try to capture all of that detail.

Get Preauthorization from the Insurer

Your insurer may require that your provider submit a request for preauthorization. The authorization explains the need for a medical procedure. Tests, procedures, and medications require preauthorization to determine medical eligibility before service.

So, ask in advance whether a test or treatment requires preauthorization and whether your planned hospital stay has been approved. Know whether your plan requires referrals for services such as seeing a specialist.

Understand Your Health Insurance Benefits if You Have Multiple Policies

The adjuster may reject your claim if the order in which it is submitted to the carriers is incorrect. So, you will need to coordinate the claim if you are sending it to multiple insurers. 

  1. Ask both insurance companies about their coordination of benefits rules.
  2. Fill out a coordination of benefits form.
  3. Identify the health benefits available to you from each policy.
  4. Coordinating the payment process.
  5. Ensuring that the primary insurance company pays first. 

Your Health Insurance Company May Reject Auto Accident or Work-Related Claims

Health insurance companies are not always liable for injuries caused by accidents, i.e., car accidents or workplace injuries. You need to send your claim to your auto insurance or worker’s compensation carriers in those cases. 

Call the liable insurer and get the case numbers, claim representative’s name and contact information, and date of injury, and keep a record. You may find that some diagnoses set off automated rejections for being “work- or injury-related,” even when they are not. It’s not unusual, for example, to see insurers deny a claim for carpal tunnel syndrome even when it has nothing to do with the patient’s work.

Don’t Worry if You Get the Bill

When you receive health services from a physician, hospital, or facility that has not contracted with your insurer, you will be billed the difference between the amount paid by the health plan and what the provider charged.

Be certain your provider is in your network. That is critical when you receive services from a hospital or medical center. The emergency room physicians may be in-network, but the radiology department personnel who interpret your tests may not be. If you receive a bill from an in-network doctor related to your deductible, make sure it is for the adjusted amount that your insurance company would have paid, not the doctor’s regular fees.

Contact Insurance Enterprise for Premier Health Insurance

If you have questions about group or individual health insurance and need health insurance quotes, contact Insurance Enterprise at 888-350-6605. Speak to a licensed agent and find out more about how you can get an affordable health insurance plan.