The Affordable Care Act (ACA) mandates that all Americans should have health insurance. However, some people, especially the young and healthy have questioned why they should pay expensive monthly premiums and out-of-pocket costs at all. Just like your auto insurance, it’s important to purchase health insurance and hope that you will never need it. The main reason for paying for your health insurance is for the unexpected, unpredictable, and uncontrollable problems that may arise.

Other Reasons Why You Need Health Insurance

To Avoid Financial Ruin

Although you may be healthy now, the onset of a serious or sudden illness such as diabetes, cancer, and appendicitis, or a traumatic event such as a car crash can cost you thousands of dollars if you don’t have health insurance. In fact, the inability to pay the expensive medical bills is one of the reasons why most people in the U.S. file for personal bankruptcy which can ruin your credit score. It will take you approximately 10 years to recover.

Health Insurance Is A Requirement by The Affordable Care Act

The recent changes under the ACA require that all Americans have health insurance. Those who fail to sign up for health insurance face hefty fines. Keep in mind that although there are other health insurance options, the form of health insurance you should enroll in is one that meets the minimum essential coverage.

Get Access to Primary and Preventive Care

Insurers are required by the law to cover yearly preventive care and checkups including vaccinations, mammograms, prostate cancer screening, and colonoscopies without copays. This means that you will be more likely to lead a healthy life and catch any health-related problems early when they are easy to treat and less expensive. Additionally, your health insurance should also provide essential health benefits that are often in ten categories: outpatient (ambulatory) care services, preventive and wellness services, emergency care, maternity and newborn care, hospitalization, prescription drugs, mental health, and pediatric care. Contrary to common belief, young and healthy people need health insurance for regular checkups, preventive care, and chronic disease management, in case they have diabetes, asthma, or any other condition.

Get follow-Up Care

The emergency departments of most hospitals provide care for all patients who have urgent needs such as head injuries or broken bones after an accident despite their ability to pay for the medical services. However, rehab care or other follow-up care services that can help you get back to your full function may require a substantial amount of money or a health insurance cover.

Health Insurance Claims

Making a health insurance claim involves requesting direct payment or reimbursement for any medical services that you have received. To be able to get your benefits or payment, you have to submit a health insurance claim through a claim or request form. There are two main ways of filing a health insurance claim, including:

  1. Your medical service provider can do it on your behalf by submitting the claim form directly to your insurance company either electronically or through the network.
  2. In case the health service provider isn’t in your insurance company network, you can file the health insurance claim forms on your own and send the paperwork to request payment for any medical services that you have received.

How to Submit a Health Insurance Claim Form

When filing your own health insurance claim form, you should follow these simple steps:

Request for Your Itemized Receipts

Before you file a claim you will need to obtain your itemized bill from the medical provider or doctor. An itemized bill lists all the services that you have received and the cost of each service as well as a special code that your insurance company will require for them to pay your claim. You can easily get these receipts by simply contacting your doctor and letting them know that you want to file an insurance claim, and from there they will send your itemized bill after providing some details such as your full name and the date of service.

Obtain and Fill A Claim Form

You can contact your health insurance company to get the claim form or download it from their website. The claim form will include a list of other things that they may need from your medical service provider. The claim form will enable your health insurance company to learn more about the illness or accident in question. They need this information to determine whether the expenses you are claiming are covered under your plan. Therefore, the more information you provide the better. A typical insurance claim form will include the following sections:

  • Personal details such as your name, date of birth, and address
  • Insurance details like your group and policy number
  • Reasons why you visited the hospital and detailed background information on your condition
  • Provide your doctor’s name and address
  • Any out-of-pocket expenses that you have incurred

Submit Your Claim Form

Although submitting health insurance claim forms was often done through the mail, most health insurance companies have adopted recent technology that may allow you to submit your health insurance claims online. Therefore, before filling in the paperwork and sending through the mail, ensure that you check your insurance company’s website. If you visit your insurance company website you will find a log in button and if you don’t have the necessary information you can contact your insurance company to assist you.

Submitting your claim form electronically: Online claim forms can help accelerate payment for your claim, and sometimes it may only take 24 hours. The fast payment processing is enough reason to set up your online health insurance account. What’s more, you will also see the portion of your claim that is covered, what deductibles apply, and your co-insurance clause.

Submitting your health insurance claim via mail: In case your health insurance provider limits online forms or doesn’t offer online submission altogether, then you may have to print your claim form, fill in the details, and head to the post office. When submitting your claim form via mail, always remember to:

  • Make copies: After filling your claim form and attaching the itemized receipts from your medical services provider, ensure that you make copies of everything you send. This will help to eliminate any mistakes that may be made during the claim process and it will also be easier for you to re-file in case your claim form gets lost.
  • Always review before sending: Before you send your claim form, ensure that everything is accurate. You can do so by calling your insurance company and you can review with them all the paperwork and inquire if they may need anything else. Remember to also ask how long you should expect your claim to be paid and write down the date. After you confirm that everything is in order, you can now send the claim form. Always check the claim date and contact your health insurance company if you haven’t received your claim.

Health Insurance Claim Denial

Unfortunately, health insurance claim denial isn’t an uncommon practice. In fact, a recent survey by AARP revealed that there are approximately 200 million rejected claims every year in the U.S. alone. It can be stressing when your health insurance claim is denied. But this doesn’t mean that you have to tap into your retirement savings or apply for a loan. The good news is that your health insurance company will offer an explanation for denying your benefits through the EOB (explanation of benefits) form. The EOB contains abbreviations and codes that help explain what your insurance pays for and why your claim has been denied. The EOB will also contain a customer service number that you can call to ask questions.

What to Do After Your Health Insurance Claim Is Denied

Identify the Reason for Claim Denial

There are numerous reasons why your health insurance company can deny your claim. Take the first step and identify why your claim was denied. Also contact your doctor, hospital, or insurance company after receiving the Statement of Benefits to ascertain the reason for claim denial. Some of the common reasons for denial include:

Using an out-of-network medical services provider: In case your health insurance company is an exclusive provider organization, it may be the reason why your claim was denied. Going out of an EPO or HMO simply means that you visited a medical provider who doesn’t recognize your health insurance terms of payment. Visiting such a provider for nonemergency services may lead to denial of your claim which means that you will be responsible for all the medical expenses.

Noncovered charges: You may have undergone some medical procedures that aren’t covered by your health insurance plan. Therefore, ensure that you close check the terms of your policy because health insurance plans often don’t cover certain medical care categories, such as dental surgery or infertility treatment.

Transcription errors: Have you misspelled your name in your claim form? Is the birth date correct or does it say that you were born in 1967 instead of 1976? If you’re unable to find out why your claim wasn’t paid close check for typos. This won’t be the first time a claim has been denied due to a data entry error. If this is the case contact your health insurance company to help you fix the problem.

Pre-authorization or referral was required: Some procedures such as MRIs and CT scans often require pre-authorization. This is often the responsibility of your doctor. Sometimes your insurance will deny your claim if there was no pre-authorization. However, if your doctor ordered for these tests, request your doctor to contact your health insurance company on your behalf.

Your doctor sent the claim to a different insurance company: Sometimes your doctor’s office may bill the wrong company. Ensure that you also confirm that you have an active insurance policy. In case you visit a medical services provider that you haven’t visited for a long time, they may have your outdated insurance information. Additionally, having two policies may also cause your claim to be denied, for instance, if you’re covered through your employer as well as your spouse’s employer, it may cause problems when billing. Therefore, always double check whether your doctor has up-to-date information on file to avoid claim denial.

Re-Apply After Health Insurance Denial

Just like any other business, insurance companies are out to make money. They are able to do this by spreading the risk and retaining as much money as they can for as long as possible. However, they will have to pay up and add the loss on their balance sheets. Health insurance companies often use auditing software for reviewing claims with the intent of lowering the money they pay to hospitals and physicians. The software they use is designed to identify even the smallest technical errors in billing codes that your doctor submits for payment. However, reapplying increases your odds of approval. In case your insurance company denied your claim on the basis of a typo or coding error, you will only need to reapply once. However, in case your claim was denied due to coverage issues, you may have to reapply more than once and attach additional paperwork like a medical necessity letter from your doctor. After reapplying a few times, your insurance company will have no other option but to approve your claim.

Get Help

Whether you were involved in an accident and sustained serious injuries or you were ill, the last thing in your mind is an insurance claim denial. Receiving a letter from your health insurance company denying your claims cannot only be heartbreaking but also frustrating at a time when you’re struggling to get back to your normal self. A health insurance attorney can help you fight back after your insurance company denies your claim. Experienced health insurance attorneys are familiar with how insurance companies work, why they often deny claims and help you fight for the compensation you need.

How a Health Insurance Attorney Can Help You After Your Claim is Denied

When your health insurance denies your claim, an experienced health insurance attorney will:

Close-check the work of your health insurance company: Health insurance companies can sometimes make mistakes that can cause you big headaches, especially if you’re not familiar with how health insurance companies work. For instance, if your health insurance claim was denied because your policy has lapsed, your health insurance attorney will need a bank statement, stub or any other paperwork that will indicate the date of your last payment.

Acquire additional evidence: Sometimes your health insurance claim denial may be complicated and your health insurance attorney will have to dig deeper to gather additional evidence. For example, in case your health insurance company denies your claim on the basis that you weren’t as badly injured as you have stated in your claim form, your attorney will be required to collect additional medical evidence to counter the denial.

Appeal the health insurance claim denial: You can do this through the internal system of your health insurance company, in the courts, or through the State’s Bureau of Insurance. An experienced health insurance attorney will assist you by gathering evidence and also prepare for court dates and any hearings.

Bad Faith Health Insurance Claim Denials

Your health insurance policy is a contract. The insurance company binds itself to pay any health insurance related claims if you pay your monthly insurance premiums and meet other responsibilities such as reporting incidents in a timely manner. Just like any other contract, both parties of the agreement are expected to act in good faith. This simply means that you will be expected to interact with each other in an honest and sincere manner.

When your health insurance company denies your claim without providing a legitimate reason, then it may be violating its responsibility to act in good faith. There are different actions that can be taken for failing to act in good faith. For example, your health insurance company may be found to be acting in bad faith if it fails to communicate to you regarding your claims, in case it misrepresents the policy, doesn’t conduct a reasonable investigation, doesn’t make any attempt to settle your claims, or when the insurance company attempts to settle your claim with an unreasonably low amount. Ensure that you contact an experienced health insurance attorney if you suspect that your health insurance company is acting in bad faith. Such an attorney will help you decide whether the company has violated the contract and assist you in holding the company accountable.

Health Insurance Denial Attorney Near Me

Health insurance companies do everything possible to avoid paying claims, and they often count on the policy holder’s lack of familiarity and experience with insurance law. That is why you need an experienced and knowledgeable professional from Stop Insurance Denial Law Firm when your claim has been denied. Regardless of where you are in the United States, when facing a health insurance claim denial, you can reach our experienced health insurance attorneys on 310-878-1771 or visit our offices which are located at 229 West 31st Street Second Floor Suite #101 Los Angeles, CA 90007.