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Erik Larson writes about the job market, resume improvement, and career advice

How To Appeal An Insurance Company Decision

Written by Erik Larson, Community Blogger | Feb 5, 2018 2:16 PM

If you've been denied by a health insurance company, there's no need to get frustrated right away. There are a lot of examples of people who successfully fought for gaining their rights. There are a few things that need to be done in order to make these companies rethink their decision.

As the law provides you the rights to have an appeal with your insurer, there's a possibility of facing two procedures:

Internal Appeal - If your claim is denied or the health coverage is canceled, you have the rights to appeal to the company to reconsider your application in spite of their denial. After receiving your appeal, the insurance company is demanded to conduct a full and fair review of its decision.

External Review - In case your internal appeal has been refused, you have the rights to address an independent third party that will make a review. With the arrival of the external review, insurance companies are no longer in a position to negotiate over the claim and are required to manage your health coverage. External reviews tend to get done as soon as possible with a maximum duration of 60 days.

You were probably provided with the guidance on managing the appealing process and how to file it at the moment you were enrolled in coverage. If you need help through the process, check if your state has a Consumer Assistance Program. They can help you file an appeal and request a review from the insurance agency.

If you're facing an urgent situation, you can request an external review regardless the fact you didn't go through all of the health plan's internal appeals processes. You're also provided with the possibility of filing an expedited appeal if the usual time of the appealing process would seriously endanger your life or the possibility of regaining maximum function. In this situation, there's a high possibility of you receiving the medical coverage. According to insurance lawyer Matthew Sharp : "Insurance companies owe their customers a duty of good faith and fair dealing. Violating this duty can amount to insurance bad faith"

You're allowed to request an external review at the moment of filing an internal appeal to minimize the time. In these cases, the final decision has to be made within four working days. This decision can also be provided verbally, but is demanded to be followed by a written review within two days.

Understand the Denial

The first step towards filing a successful appeal is to get a clear vision of the insurer's reasonings. With the denial, you'll receive a statement known as Explanation Of Benefits (EOB). This form will provide you answers through codes on how the insurer came to the decision. If you aren't completely sure even after going through this statement, you have the right to call the agency. The insurer required to simplify the reasonings in order for you to understand.

Archive All Evidence

Be sure to document everything that may be used in your interest the second time you appeal to the insurance agency. Gain access to your medical history if it is relevant to your current situation. Prescriptions and referrals are also highly suggested to be used as evidence for the medical coverage. Ask your doctor to guideline the treatment you've received, since it will also be a valuable piece of information.

Gather Your Paperwork

As the insurance company has its own ways of tracking your file, you want to be as organized as possible in order to follow up the procedure. Be sure to call often in order to check your status. If you're appeal is submitted, get informed about its 'document image number'. Take notes of every phone call you've done with the insurance agency. You'll be in touch with different customer service agents. With provided information about your claim they'll be able to access your files faster and speed up the process.

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