| tart --> | | | | on the phone. |
| Medical insurance claims are denied for all sorts of | | | | 4. If you do understand the reason, but disagree, call |
| reasons. What do you do if you feel the insurance | | | | the insurance company. Explain why you disagree to |
| company should have paid on a claim but has denied | | | | the representative and ask what it will take to get |
| it? | | | | this claim paid. |
| Having run a medical billing service for twelve years, | | | | 5. If the claim has been denied for a reason which |
| we've see a lot of denials on claims. The biggest key | | | | can be remedied, ask the representative exactly |
| to getting a claim paid when it is denied incorrectly is | | | | what you must do to correct the situation. If you |
| to act on it immediately. Sometimes in a busy medical | | | | are the patient or calling for the patient, this may |
| office, there is a tendency to put a denial in a pile or | | | | involve calling your doctor's office and explaining to |
| drawer or take care of it later, but this is a mistake. | | | | the billing manager what you have found out and |
| The sooner the problem is dealt with, the more likely | | | | asking them to follow through. |
| you are to get the decision reversed and the claim | | | | 6. The representative may tell you that the claim has |
| paid. | | | | been denied correctly. That does not necessarily |
| Here's how: | | | | mean that they will not pay. The claim may have |
| 1. Look the denial over carefully. Look for a denial | | | | been denied for timely filing. If the billing office |
| code that may be numbers or letters or a | | | | resubmits the claim with proof of timely filing, the |
| combination. Now search for the explanation of the | | | | decision may be reversed. (Incidentally, if the claim is |
| denial codes, sometimes found at the bottom of the | | | | denied for timely filing, the patient cannot legally be |
| remittance. It may not make sense to you, but that | | | | billed.) The claim may have been denied for incorrect |
| does not matter. Right now you just want to know | | | | ID#. In this case, the ID# is corrected and the claim |
| their reason for denying the bill. | | | | is resubmitted. |
| 2. Once you determine the insurance company's | | | | 7. If you cannot get a solution to your problem with |
| reason for denying a claim, you have a better idea of | | | | a phone call, it may be necessary to file a written |
| what to do. If the reason makes absolutely no | | | | appeal to the insurance company. Ask the |
| sense, call the insurance company. There is usually a | | | | representative where you should send your written |
| phone number on the denial form. Calmly explain the | | | | appeal. Explain your situation entirely and the reasons |
| situation to the customer service representative. | | | | you feel this claim should have been paid. Keep |
| These representatives have to deal with calls like this | | | | copies of all correspondence and notes of all |
| all day, so it is much better to treat them | | | | telephone conversations. Write down who you spoke |
| respectfully. Remember, if a mistake was made, it | | | | to, when it was, and what they told you. |
| wasn't this person who made it; they are going to | | | | Whether you are an individual trying to get your |
| correct it for you. Be nice. | | | | medical bill paid or you are from a doctor's office, |
| 3. If you don't understand the reason at all, call the | | | | make sure you keep good notes of everyone you |
| insurance company and ask for an explanation you | | | | talk to or write concerning the problem. This can be |
| do understand. It is very common for an insurance | | | | the key to getting your claim paid. If you are an |
| company to deny a claim incorrectly or because | | | | individual, get the doctor's office involved in helping |
| there was not enough information on the claim form. | | | | you with your problem. Many times they know who |
| If they have denied the claim incorrectly, many times | | | | to speak to or how to handle the problem. |
| the representative can fix the problem while you are | | | | |