The Importance of Making Appeals Within the Health Insurance World

Imagine this: you have to suddenly rush out to the hospital for a health condition. At this point in time, you’re not thinking about anything but taking care of the problem and getting back to living life with your family. You give the hospital staff your insurance card and sit back, thinking that your task is over. You can get the care you deserve, without having to break the bank to pay for it. After all, isn’t that the exact reason why you have health insurance in the first place?

Your treatment goes well…but your health insurance company denies your coverage. This means that you will now have to figure out how to pay for your hospital bills. This can be a tremendous burden and strain on your family, but it doesn’t have to be this way at all. First and foremost, you should understand that it’s important to make sure that you can make an insurance appeal. Not only that, it’s absolutely important that you do make an appeal if you feel that you should have coverage for the event in question.

Let’s face it — insurance companies aren’t right about everything. The good news is that if you can actually make a case for why you should have the event covered, then you stand a good chance at getting your claim approved.

Like most things in life, there is actually a process that you will need to follow if you want to maximize your chances of getting your claim approved. First and foremost, you will want to look at your Explanation of Benefits statement. The appeals process should be listed there, but you can always call and get more information for your specific insurance company. It’s better to make sure that you will be able to get the coverage that you need rather than trying to run in circles.

Now, at this point most guides say that you should do your appeal over the phone or online. This is actually not as good of an idea as you might think for several reasons. The biggest reason is that it’s difficult to get a “paper trail” to make sure that things are actually being handled. It’s too easy for records to disappear saying that you never called in, which would make the decision final — after all, you only have a limited time to appeal an insurance company’s decision. You just need to send in a letter. It might seem outdated to send a letter when business is done over the phone or online now, but it’s the only way to ensure that you will have a formal appeal process started. Make sure that when you mail your letter off that you actually mail it out certified mail, return receipt requested (CMRRR). CMRRR is the best way to send out all legal-oriented documents, because you will know immediately when it’s received. There’s no reason not to spring for this service, since it will only help you in the long run.

Once you’ve filed your appeal, you must make sure that you’re giving the company enough time to actually review your case and make a decision. Considering that you will be mailing your appeal in, you must make sure that you give the process at least 30-60 days. Since there is a dispute involved, your credit will not be immediately affected in the long term sense. You will still have to file additional papers with the credit card bureau, but that’s not what’s important at this point. The important point is to make sure that you get heard.

The appeal process mentioned thus far is considered to be an internal appeal — if you don’t get any results from an internal appeal, you might want to make sure that you get the instructions for filing an external request for review through your state’s department of insurance.

You don’t have to feel like you have to accept your initial decision — it’s important to get a clear reason why a certain procedure was denied. Make sure that you bring your doctor into the loop on this — they will also be valuable in helping you get a decision overturned.