Insurance companies recognize the air of confusion that accompanies a policy holder’s receipt of a denial letter. Policy holders pay for the ability to gain access to benefits. The thought that such benefits have been denied can seem so frightening that the denied customer does not know what to do.
Yet there are things that a denied policy holder can do. There are questions that such a person can ask. The answers to such questions help with formulation of a way to fight the denial.
Was it an automatic denial?
Was there a misspelling in the application?
Did the requested amount exceed a threshold established by the insurer? Did the submitted form contain a request that the insurer could not fulfill? If any of those possibilities proves to be the case, the policy holder can submit a corrected application.
Problems that can get resolved through an internal review:
• Did the insurance company want a pre-authorization or a referral?
• Was the claim filed late?
• Did the policy holder’s medical history fail to support a need for the requested service?
• Was the policy holder’s request for a high level of service, one that exceeds that same individual’s true needs?
Problems that call for completion of an external review:
The insurance company does not work with any provider that can furnish the requested service. The submitted form contains a request for a service that is investigational or experimental in nature.
A policy holder can contact an external review organization by initiating the process that should lead to the launch of an external appeal. Realize that a policy holder has only 180 days in which to file an appeal. The timeline starts on the day when the original request was denied.
Information to seek before launching such an appeal:
Get the name of the person that reviewed the submitted request. Seek information on the credentials possessed by that same reviewer. A personal injury lawyer in Leduc knows that the denial is made by someone that has reviewed a submitted form.
Actions to take if a first appeal gets denied:
In lieu of initiating a second appeal, the policy holder can speak with the healthcare provider. That provider should be consulted, regarding his or her willingness to accept a lower fee, or to agree to delivery of a series of payments. Such an approach should involve less effort than the alternative approach, that of dealing with a second appeal.
It can prove a challenge to determine the start date for the timeline in a second appeal process. Insurers tend to use different dates as the start of that specific timeline. By speaking with a provider, a policy holder can avoid the confusion that arises, with respect to that same timeline.