IN­SUR­ANCE

The News Herald (Willoughby, OH) - - Advertising - Laura Mut­sko Agent, CSA and Cer­ti­fied Health­care Re­form Spe­cial­ist

Q: What are some com­mon rea­sons for an in­sur­ance claim to be de­nied? How do I ap­peal their de­ci­sion? A: Hav­ing your in­sur­ance claim de­nied is a frus­trat­ing and some­times fright­en­ing ex­pe­ri­ence. Un­for­tu­nately, it is not un­com­mon. Across the health­care in­dus­try, the av­er­age claim de­nial rate is be­tween 5% and 10% ac­cord­ing to the Amer­i­can Academy of Fam­ily Physi­cians (AAFP). Some of the most com­mon rea­sons for de­nial:

• Data en­try er­rors (miss­ing or in­cor­rect in­for­ma­tion) • No prior au­tho­riza­tion • Cod­ing er­rors • Past timely fil­ing lim­its • Ques­tions on med­i­cal ne­ces­sity • Pa­tient re­spon­si­bil­ity (Co-Pay, De­ductibles, etc.) Many claims that are ini­tially de­nied can be suc­cess­fully ap­pealed. Here are steps you can take. Be­gin with your Ex­pla­na­tion of Ben­e­fits (EOBs). It will list the rea­son your claim was de­nied. You can also con­tact your in­sur­ance com­pany and ask for an ex­pla­na­tion. You have a right to this in­for­ma­tion. Next, check your pa­per­work for eas­ily cor­rectable is­sues in­clud­ing the spell­ing of your name, ad­dress, in­sur­ance ID num­ber and dates of ser­vice. If any of these are in­cor­rect, con­tact your in­surer with the cor­rect in­for­ma­tion. If it was an er­ror on the part of your doc­tor or other provider, re­port the er­ror to them and ask that they re­sub­mit the claim.

If ev­ery­thing ap­pears cor­rect, your next step will be to gather your ev­i­dence for an ap­peal. You will need to show that the ser­vices you want cov­ered are med­i­cally nec­es­sary. Re­fer­rals, pre­scrip­tions from your doc­tor and any rel­e­vant in­for­ma­tion about your med­i­cal his­tory may help your claim. En­list your health care providers’ as­sis­tance with this step. Armed with this in­for­ma­tion you are ready to file a for­mal ap­peal. The EOB you re­ceived from your in­sur­ance provider should tell you how to do this or con­tact your in­sur­ance com­pany for guid­ance on this step.

It is im­por­tant to keep all your in­for­ma­tion or­ga­nized as you go through the ap­peal process. Take care­ful notes dur­ing ev­ery phone call with the in­sur­ance com­pany. Note the name and ti­tle of each per­son you speak to along with the date of each con­ver­sa­tion. Ask if there is a track­ing or ref­er­ence num­ber so the next per­son you talk to can eas­ily ac­cess your in­for­ma­tion to help move your ap­peal along. If your claim is de­nied a sec­ond time, ask how you can take it to the next level. If you have ques­tions con­cern­ing Health In­sur­ance in­clud­ing In­di­vid­ual, Group, Medi­care Ad­van­tage Plans or Medi­care Sup­ple­ments, call me at 440255-2500 or email me at Lmut­[email protected] mut­skoin­sur­ance.com. I look for­ward to help­ing you. Laura Mut­sko Mut­sko In­sur­ance Ser­vices, LLC 6982 Spinach Drive, Men­tor, OH 44060 440-255-5700 www.mut­skoin­sur­ance.com

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