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Checklist: Disputing A Health Insurance Denial
Sometimes insurance companies don't want to pay for services that you believe they should cover. When that happens, you can dispute their decision. Below is a checklist to use when trying to get a company to reverse its denial of coverage.
Check off each item as it is completed.
| _____ | Find the insurance contract--it is the multi-page document that outlines your medical insurance coverage. |
| _____ | Read the sections on what services are covered, and which are excluded. |
| _____ | Highlight references showing that the insurer covers services like the ones it denied, and any exclusions that relate to your denied claim. |
| _____ | Gather all claim denial notices, medical billing statements, notes, and other documentation. Circle invoice numbers and dates of denied services. |
| _____ | If it appears that information is missing, call your doctor's office. The billing department may have neglected to fill in a crucial item. If this is the case, the doctor's office should correct and resubmit the claim. |
| _____ | With this information and the insurance contract, call your health insurer's customer service number. Call early in the day to avoid extended hold times. Do not, under any circumstances, leave a message rather than talking to a representative in person. |
| _____ | Explain to the representative that after carefully reviewing your coverage, you believe the claim should be paid. Be firm, calm, and specific. Discuss the relevant sections in the insurance contract. Showing that you are knowledgeable about your coverage will give the representative less wiggle-room. If the representative does not seem like he knows what he is talking about, or is rude or dismissive, or if you feel the issue is more complicated than a low-level representative can handle, don't feel shy about requesting to talk with a supervisor. Never accept an assertion that a service or product that used to be covered is no longer covered without a complete, written explanation. |
| _____ | Document all calls, writing down the date and time of your call, the full names and extensions of all company representatives you speak with, and the details and results of the conversations. If the dispute gets drawn out, or if you wind up suing your insurer, the documentation will be key. |
| _____ | Insist that the representative give you a date by which your claim will be resolved, and that you receive notice of the resolution in writing. Call the representative back immediately if the matter is not resolved by that date. Some insurers count on customers giving up, so be persistent. |
| _____ | If the claim is not paid, or if the company is unresponsive, call the state insurance commissioner's office and file a complaint. The office can investigate a denial, and help you get the matter resolved. If this fails, you may need to discuss the matter with an attorney. |
| _____ | When the claim is paid, double-check that the amount paid agrees with the terms of your plan. For example, the insurance company can't stick you for 50 percent of the bill if it is supposed to cover 70 percent of the cost. |
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