When medical claims are submitted to an insurance company, they must first go through a clearinghouse. This helps standardize and screen claims before submission in order to reduce errors and rejections.
Insurance companies use adjudication to assess medical claims, which is when they determine if and how much compensation should be granted back.
Internal Appeal
Health insurance companies must inform you of whether they have approved or denied your claim within a set amount of time. Rules vary by state; you should refer to your plan’s policy to find out when they must respond; Minnesota and Texas require companies to respond within five days, while Virginia allows 90. Your plan’s policy should also outline an appeals process; most insurers have internal first level appeals followed by external review, allowing you to go above the company head and be heard by an impartial panel who didn’t play a part in making their initial decision.
Staying organized and patient during an internal appeal process can speed things up significantly, speeding things along significantly faster. Keep all paperwork together to avoid losing any documents or contact information; additionally it can be helpful to record all conversations with insurers or doctors – writing down each time and the topic discussed as a reminder for future conversations. You may need to send extra paperwork like medical records and proof of financial hardship directly to them for consideration as part of their review; also ask any doctor or hospital you visit not to send bills until hearing back from them first as this could prevent them turning you over for review instead of collections.
Once your internal appeal is submitted to an insurance company, they will either approve it or deny it. If denied, an external review can be requested from your state’s insurance department where someone who doesn’t work for your insurer will review all aspects of the case and give a final verdict – although expedited review options can sometimes be availed of.
Through interviews with consumers, we discovered that health insurers often fail to offer clear instructions for accessing your own claims files. When guidance does exist, it may be buried within denial letters and websites – yet those who successfully gain access often uncover information that proves profoundly enlightening – such as case notes detailing how their claims were funneled into programs meant to cut costs or audio recordings containing audio calls that proved misinformation by insurance representatives.
External Appeal
Under the Affordable Care Act, every health insurer is mandated to offer patients an external appeal process so they may request someone who does not work for them to review a decision to deny a claim – this process is known as external review or appeal and most states mandate independent third-party reviews be performed as such.
External reviewers typically consist of medical professionals trained in reviewing specific cases. They will examine all of the facts regarding your situation before rendering a verdict based on their review; depending on state laws, they may overturn or issue new decisions from insurers as a result of their review process. In certain states, an external reviewer must also provide their decision back to them for their own records.
Most insurance companies will inform you of your options to file an external review when they send a final decision regarding your appeal. In order to do so, however, all steps in your plan’s internal review process must first be completed prior to filing an external appeal.
If your health insurance provider refuses to cover treatment you need, contact your state’s department of insurance for information on filing an external appeal. Most states offer forms on their websites or have hotlines you can call to receive the correct form and instructions; typically these forms require filling in all the relevant information before being signed and dated by you and then filed away.
Your deadline to file for an external review with your health insurer will typically be four months from when they issued their final denial letter; some states have different deadlines. If time is running short, an expedited review can also be requested.
Before initiating an appeals process, be sure to review your health insurance policy thoroughly. Most policies offer an online summary of benefits; you may also ask your employer, health insurance provider, or broker (depending on where you got it) for a copy.
Administrative Hearing
Health insurance company delays may be frustrating, but you should remain patient and approach the situation with an open mind and solutions-oriented mindset. Most often, delays in claims processing stem from internal billing guidelines or coding procedures that take time for your insurer to understand. Furthermore, your healthcare provider may require additional information from either you or your physician in order to complete their claim process. In many instances, insurance companies must give an explanation as to why their claim has been delayed or denied before proceeding further with it.
If your claim has been denied, don’t lose hope; most denied claims can often be reversed with new evidence. To file a review request you will require your plan ID and unique member ID (usually found on your health insurance card), along with case number(s). These details can usually be found by reviewing the first page of an explanation of benefits (EOP) or electronic remittance advice sent directly to either yourself or provider.
Once you have all of the relevant information, you or your attorney can compile a demand package with medical records, referrals and prescriptions relating to your injury and its effect. This package should then be sent along with a letter summarizing your case as well as any additional details or additional evidence you wish the insurance company to consider.
Your state regulations and health insurance plan usually allow for you to file an external review or administrative hearing with their provider, in which an independent health care professional reviews your claim and makes a decision about it.
Fighting health insurers over claim denial may seem like an impossible battleground; however, studies show that consumers can often win. Before embarking on any appeals process it’s crucial to know all aspects of your health plan policy as well as consult an expert consumer assistance program for guidance.
Duration of an administrative hearing depends on your state laws and complexity of your case, but typically within 30 days after close of hearing record a judge should issue their recommended decision.
Court Hearing
Once an appeal is filed, the insurance company must review it to reach a decision and either pay out or deny the claim. This process usually takes between 1-14 weeks depending on its complexity.
Reconciling your claim status regularly will help reduce delays caused by inaccurate or errors information. If you need any help understanding what the status is for your claim, feel free to reach out the customer service department of your insurance provider; their customer service representative should be able to give an explanation and answer any queries that might arise about its progress.
Your claim’s status may take anywhere from 30 days to several years for completion, including non-payment of the deductible or co-pay resulting in rejection from an insurance provider. In such a scenario, resolution could take significantly longer.
To ensure that your claim is processed efficiently, provide accurate medical codes and detailed documentation that reduces the risk of rejection. Furthermore, keep up with payments so your account remains in order and avoid late fees being assessed against it.
Be prepared for a lengthy wait when dealing with large insurance companies. An investigator may be assigned to investigate multiple claims at once, which may result in delays. Hiring a medical billing professional or outsourcing your billing process to an outside vendor may help expedite the process by decreasing rejections and appeals.
Claims processing can be an extremely time-consuming and complicated process, which may require expert assistance to be successful. An efficient team with relevant experience will ensure that claims are processed efficiently and accurately, leading to quicker payments and increased cash flow for your practice.
