Tips on Appealing Denied Health Insurance Claims

Claims insurance companies have many processes in place to ensure their money, or their client's money, is protected. Whether you are the subscriber of a Third Party Administrator (TPA - a plan administered according to your employer's specifications) or a Health Maintenance Organization (HMO - a plan administered according to the health insurance company's specifications), you have resources that are available to you in the event that a medical claim is denied. This article will outline some of those resources, and tips for ensuring you are not paying for services that the insurance company is responsible for.

1. With every claim submitted to your insurance company by your doctor or hospital (the provider of service) you should receive an Explanation of Benefits (referred to as the EOB). Whenever the insurance company submits and EOB to you, a copy is sent to your provider of service. Save each and every EOB, even if it is only stating that nothing is being paid because it is a duplicate claim. Each EOB corresponds to a claim number in your health insurance company's system. When contacting them, it will be most beneficial to be able to reference the EOB or claim that the customer service representative is referring to.

2. When contacting customer service always write down the customer service representative's name, the date and time you're calling, and any specific details of your conversation. It is standard practice for Customer Service Representatives (CSR) to take notes of every call they have taken throughout their shift. If you have your own record of your call that is more detailed, it is likely that your call will be taken more seriously by another CSR or, if necessary, their Supervisor. This detailed account will also be very useful should it become necessary for you to write an appeal to the insurance company.